RADIOLOGY REQUEST FOR X-RAY AND ULTRASOUND EXAMS
Today’s Date:
___/___/_____
Priority: STAT or Routine
Date Requested: ___/___/_____
Tel 800-749-XRAY Fax 718-228-9318
www.pdihealth.com
PATIENT NAME
SS#
DOB
FACILITY / HOME ADDRESS
MEDICARE #
AGE
SECONDARY INS.
UNIT/ROOM #
PHONE
DIAGNOSTIC CODE / REASON
SEX
MEDICAID #
POLICY #
GROUP#
OTHER INS.
[PRIOR HMO] APPROVAL
EXT.
____________________________________________________________
PATIENT OR NURSE’S SIGNATURE
(IF PATIENT UNABLE TO SIGN)
___________________________________________________________
PHYSICIAN SIGNATURE AND/OR DOCTORS LAST NAME
(REQUIRED)
X-RAY EXAMS
ABDOMEN
ABDOMEN
74000
ABDOMEN FLAT & UPRIGHT
74020
CHEST
CHEST
71010
CHEST AP & LATERAL
71020
R L RIBS UNILAT INCL. AP CHEST
71101
RIBS BILAT. INCL. AP CHEST
71111
BONE STUDIES
R L ANKLE (COMPLETE)
73610
R L CLAVICLE (2 VIEW )
73000
R L ELBOW (COMPLETE)
73080
R L FEMUR (AP & LATERAL)
73550
R L FINGERS (COMPLETE)
73140
R L FOOT COMPLETE
73630
R L FOREARM (AP & LATERAL)
73090
R L HAND (COMPLETE)
73130
R L HEEL (OSCALSIS)
73650
R L HIP (AP & LATERAL)
73510
HIPS BILATERAL W/ PELVIS
73520
R L HUMERUS (AP & LATERAL)
73060
R L KNEE (AP & LATERAL)
73562
L (SINGLE VIEW)
PELVIS
72170
SACROILIAC JOINTS
72202
SACRUM AND COCCYX
72220
R L SCAPULA (COMPLETE)
73010
R L SHOULDER (COMPLETE)
73030
R L TIB/FIB (AP & LATERAL)
73590
R L TOES (COMPLETE)
73660
R L WRIST (COMPLETE)
73110
HEAD
FACIAL BONES
70150
R L MANDIBLE LIMITED
70100
NASAL BONES
70160
SKULL
70250
SINUSES
70210
SPINE
CERVICAL SPINE (AP & LATERAL)
72040
LUMBAR SPINE (AP & LATERAL)
72100
THORACIC SPINE (AP & LATERAL)
72070
CARDIAC
EKG
93000
HOLTER MONITOR (93225, 93226)
PACEMAKER EVAL.
93294-DUAL 93293-SINGLE
ULTRASOUND EXAMS
ECHOCARDIOGRAM
CARDIAC
GENERAL ULTRASOUND
ABDOMEN ULTRASOUND
ABDOMEN (LIMITED)
AORTA
BREAST (Radiologist Approval Req.)
PELVIC ULTRASOUND
PELVIC (LIMITED)
RENAL
TESTICULAR (SCROTUM)
THYROID
93306
/_ ___
/_
____
____
TECHNOLOGIST :
76700, 76700
76705
76770, 93975
76645
76856
76857
76770
76870, 93975
76536
DOPPLER ULTRASOUND
ARTERIAL DUPLEX BILATERAL
R L ARTERIAL DUPLEX UNILATERAL
NUMBER
OF FILMS:
NUMBERS
OF VIEWS:
PATIENTS SEEN
THIS VISIT:
93925
93926
VENOUS EXTREMITY BILATERAL
93970
R L VENOUS EXTREMITY UNILATERAL
93971
CAROTID DUPLEX DOPPLER
93880, 93875
DUPLEX SCAN;
93976
ABDOMINAL/PELVIC/SCROTAL (LIMITED)
ALL ABDOMINAL ULTRASOUND EXAMS REQUIRE THE
PATIENT TO BE NPO FOR AT LEAST 6-8 HOURS PRIOR TO
THE EXAM
PELVIC ULTRASOUND EXAMS REQUIRE THE PATIENT TO
HAVE A FULL URINARY BLADDER (32 OUNCES OF FLUID 1
HOUR PRIOR TO EXAM)
BECAUSE OF ADVANCED AGE AND PHYSICAL
LIMITATATIONS, THIS PATIENT IS UNABLE TO RECEIVE
RADIOLOGY SERVICES OUTSIDE THIS LOCATION. THIS
TEST IS MEDICALLY NECESSARY FOR THE DIAGNOSIS
AND TREATMENT OF THIS PATIENT.
FACILITY NOTES:
DATE
PERFORMED:
CASSETTE
NUMBERS:
OFFICE USE
ONLY: