PLACE LABEL HERE
OUTPATIENT ORDERS – PRECERTIFIED EXAMS
Imaging Services
Imaging Scheduling:
Phone:
Fax:
678-312-3444
678-312-9736
Precertification: 678-312-4095
Location of Scheduled Appointment:
 Gwinnett Medical Center – Lawrenceville
 575 Outpatient Imaging Center
 Gwinnett Medical Center – Duluth
 Outpatient Center at GMC – Duluth
 GMC Imaging Center – Hamilton Mill
GMC to Schedule Patient?  Yes  No
Patient already scheduled?  Yes  No
Appointment Date: ____________________
Arrival Time: _________________
Exam Time: _________________
GMC to Precert Patient?  Yes  No
*If yes, copy of insurance card & clinical
documentation must be sent with order*
Medicare?  Yes  No
Precertification # : ______________________
NAME: _______________________________
DOB: ________________________________
Phone#1: _________________________________
Phone#2: _________________________________
Language: _________________________________
PATIENT MUST BRING THIS ORDER ON THE
DATE OF SERIVCE.
Allergies: ____________________________________________________________________
Symptoms/Diagnosis: _______________________________________________________________________________________________________
EVALUATE CREATININE LEVEL PRIOR TO TEST UNLESS LEVEL PERFORMED WITHIN 7 DAYS. RESULT:____________
MRI
MRI/CT ANGIOGRAPHY
CT
NUCLEAR MEDICINE
 Contrast per Radiologist
discretion
 With Contrast
 Without Contrast
 With and Without Contrast
 With Contrast
 Without Contrast
 With and Without Contrast
 Contrast per Radiologist
discretion
 With Contrast
 Without Contrast
 With and Without Contrast
 Prefer Open High Field MRI
 Orbits for MRI clearance
MRI Angiography
Neuro:
 Circle of Willis (Intracranial)
 Carotid Bifurcations
 Abdomen (Aorta, Renals,
Mesenteric)
 Pelvis
 Run-off (Aorta and Bilateral
legs)
 MR Venography - Brain
 Other: ________________
Head
Neck (soft tissue)
Sinus
Temporal Bone
Neuro:
 Brain
 Neck (soft tissue)
 Pituitary
 IAC
Spine:
 Cervical
 Thoracic
 Lumbar
 Sacrum-SI Joints
Abdominal:
 Abdomen
 MRCP
 Adrenals
 Kidney
 Liver
 Pelvis (Gyn–Prostate)
Cardiac:
 Cardiac
CT Angiography
 Brain (Aneurysm)
 Head/Neck (Stenosis/TIA)
 Chest  Pulmonary  Aortic
 Abdomen AND Pelvis
(Renals OR  Mesenteric)
 Pelvis
 Run-off (Aorta and Bilateral
legs)
 Other: _________________
OTHER
Musculoskeletal:
 Rt  Lt  Bilateral
 Shoulder
 Hip
 Elbow
 Knee
 Wrist
 Ankle
 Pelvis (Bony)/Hip
 Foot
 Bone:____________________
 Arthrogram (with contrast)
Site______________________
 Breast:
 Rt  Lt  Bilateral
 3D Reconstruction
 ___________________________
 ___________________________
ANESTHESIA
Requests for anesthesia must
be scheduled through
Imaging Scheduling.
 Anxiolysis/Anesthesia
Spine:
Cervical
Thoracic
Specify Levels____________
Lumbar
Post Myelogram
3D Recons
Body Imaging:
Chest
Abdomen AND Pelvis
Abdomen Only
Pelvis Only
Renal Stone Panel
(Abdomen & Pelvis w/o contrast)
Enterography (Volumen)
(Abdomen & Pelvis w contrast)
Musculoskeletal:
Upper Extremity w/ 3D Recons
Lower Extremity w/ 3D Recons
Rt  Lt
Site:______________________
SI Joints w/ 3D Recons
Bony Pelvis w/ 3D Recons
Arthrogram (with contrast)
Site_____________________
Biopsy: (CT guided)
Bone Scan:
(with correlating films if medically
necessary)
 Whole Body
 Limited
 Three Phase
Gastric Emptying
Hepatobiliary (HIDA)
 With Pharmacological
Intervention for EF
Lung Scan (V/Q)
Parathyroid (Without SPECT/CT)
Renal
with Lasix (furosemide)
with Vasotec (enalapril)
Thyroid Uptake & Scan
WBC Scan (Indium/Ceretec)
Other: _____________________
SPECT/CT
Bone Scan (With SPECT/CT) (with
correlating films if medically necessary)
 Whole Body,
Area of Interest ___________
 Limited
 Three Phase
Parathyroid (With SPECT/CT)
Octreoscan
Prostascint (chest/abd/pelvis)
Other:______________________
PET/CT
***Please Use Dedicated
PET/CT Order Form # 26113***
Specify: ________________
Requested
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
 STAT Results to:  Phone or  Fax: ________________
____________
Date
_________
Time
 Hold Patient and Call Physician’s cell #: ____________________
____________________________ __________________________ ______________
Physician Signature
Physician Name (print)
PID Number
Tests should only be ordered that are medically necessary for the diagnosis, symptoms, and/or treatment. The patient may be billed for tests that are not deemed necessary by
payors. Please submit all (appropriate) clinical indications for all test(s) ordered. The procedure will not be performed in the absence of the completed form including the
appropriate diagnosis and/or ICD-9 code supporting the ordered procedure. Ordering physicians are responsible for the accuracy of the information provided.
*1-18693*
1
FORM 1-18693 REV. 09/2015
WHITE: Medical Record
CANARY: Physician Office
Page 1 of
OUTPATIENT ORDERS – PRECERTIFIED EXAMS
Imaging
Services
Reference Page and click onto the facility where you are scheduled.
go to WWW.GWCIMAGING.ORG
For directions,
Gwinnett Medical Center - Duluth
3620 Howell Ferry Road
Duluth, Georgia 30096
phone: 678-312-6693
Gwinnett Medical Center
1000 Medical Center Boulevard
Lawrenceville, Georgia 30046
phone: 678-312-4440
Outpatient Center at Gwinnett Medical
Center - Duluth
3805 Pleasant Hill Road
Duluth, Georgia 30096
phone: 678-312-7000
575 Outpatient Imaging Center
575 Professional Drive, Suite 400
Lawrenceville, Georgia 30046
phone: 678-312-5300
GMC Imaging Center – Hamilton Mill
2078 Teron Trace, Suite 200
Dacula, GA 30019
678-312-8600
GMC PET/CT & 3T MRI
631 Professional Drive, Suite 190
Lawrenceville, Georgia 30046
phone: 678-312-5300
*PET/CT & MRI ONLY*
FORM 1-18693
REV. 09/2015
Reference Page