PS1052
1A/PS1052
cgi proof #2 (01/16/15)
Imaging Services Scheduling Order Form
FAX orders to: 404.501.1743
Phone: 404.501.2660
Tax ID Number 58-1966795
Patient Information / Ordering Information
Patient Name:______________________________________________ DOB:____________________ Sex: q M q F SS #: XXX-XX- _______
Home Phone #:_________________________ Mobile Phone #:________________________________
Insurance:____________________________________ Are we ruling
Policy #:_____________________________
q Call patient to schedule
q Patient will call
q Patient already scheduled
out a specific diagnosis (specify):_________________________________________
ICD - __________ SYMPTOMS / DIAGNOSIS:_______________________________________
Should DeKalb Medical pre-cert this
procedure on behalf of the physician?
Appointment date/time:__________________________________________________________
q Yes q No
SPECIAL REQUEST (Please check all that apply)
Pre-cert # (if necessary):
q STAT call report #: _________________________________
q FAX # (if different than AutoFAX #):
CT
Contrast: q Without q With q With and without
q At discretion of Radiologist
qAbdomen
qChest
q CTA Chest (PE)
qPelvis
q High resolution chestq CTA Neck
q Renal stone protocol qHead
q CTA Head
q Pancreatic Protocol qSinus
qMaxillofacial
q Triple Phase Liver
q Soft tissue neck
q CT Enteroclysis
q Hematuria Protocol q Low dose lung
q AAA protocol (A/P only)
q Renal Mass Protocol q Cardiac scoring
q CTA Dissection (C/A/P)
qSpine (specify):__________________________________________
qExtremity (specify)_______________________________________
qOther:__________________________________________________
q Send films with patient
q CD images
________________________________
Mammography/Breast Ultrasound
Screening mammogram
q Bilateral
q Unilateralq R q L
Diagnostic mammogram
q Bilateral
q Unilateralq R q L
Breast ultrasound
q Bilateral
q Unilateralq R q L
q Other:_____________________________________________________
Bone Density (For osteoporosis)
q DEXA Axial Skeleton
q Heel Scan
q Vertebral Assessment (VFA)
Interventional Radiology (please attach lab specimen sheet)
q Arteriogram (specify type):____________________________________
q Venous procedure (specify type):_______________________________
q Embolization (specify type):___________________________________
q Biopsy (specify type):________________________________________
q Drainage (specify type):______________________________________
q Other:_____________________________________________________
PROOF #2
MRI
Contrast: q Without
q With and without
q At discretion of Radiologist
q MRI brain
q Lumbar spine
qKnee
q Left q Right
q MRA brain
q Cervical spine
qShoulder q Left q Right
qPituitary
q Thoracic spine
qHips
q Left q Right
qPelvis
qMRCP
q Breast Biopsy (MR guided)
qProstate
qEnterography
qBreast
qAbdomen (Please specify organ):___________________________
q MR angiography (specify):_________________________________
q Other:_________________________________________________
Ultrasound
qAbdomen
qPelvic
q Pelvic with transvaginal
qThyroid
q Abdominal wall mass q Cervical lymph node
qRenal
qAorta
qTesticles
qOB
q OB with transvaginal qBPP
Extremity (non vascular-specify):______________________________
Other:____________________________________________________
Nuclear Medicine
q Thyroid uptake and scan q Dual isotope heart scan
qLung
q Bone Scan: q Whole Body q 3 phase
q Gastric Emptying
qRenal: q With Lasix q Without Lasix
q Hida Scan q Hida with CCK
q Thyroid Therapy q Other:_________________________________
PET/CT:__________________________________________________
Routine X-Ray
q Chest, PA and lateral (71020)
q Flat abdomen (KUB) (74020)
q Acute abdominal series (74022)
q Cervical spine 4 view (72050)
q Thoracic spine (72072)
q Lumbar spine 2-3 view(72100)
q Bone survey (multiple myeloma or mets) (77075)
q Ribs (71100)
q Left q Right
q Extremity (please specify):_________________________ q Left Right
q Other: (CPT Codes Required)_________________________________
Fluoro
q Barium swallow
q Barium enema
q Barium enema – air contrast
q Upper GI series
q Small bowel series
q Hysterosalpingogram
q Arthrogram (specify site):_____________________________________
q Other:_____________________________________________________
GU Tract
q IV Pyelogram
q Cystogram, voiding
q Retrograde Urethrogram
q Other:_____________________________________________________
EKG
q EKG q Rhythm Strip
q Stress Test
q Holter monitor
q Other:_____________________________________________________
EEG
q EEG q Sleep EEG
q SSEP
q VEP q BHER
q Comments:_________________________________________________
Heart and Vascular
q Extremity
q Venous blood flow -
q Upper q Lower
q Carotid
q Arterial blood flow -
q Upper q Lower
q Echocardiogram Specialists:___________________________________
q Other:_____________________________________________________
Referring Physician Information
Physician Name (first & last):______________________________________________NPI#:___________________________
Phone #:____________________ Fax #:__________________________________
GA License #:____________________
I hereby certify that the services indicated in the above order form are medically necessary.
Physician Signature:________________________________________________Date:______________________ Time:_____________________
PS-1052 (1/15)