Request for Out Patient
Imaging
Patient Information
Name (LAST, FIRST, MIDDLE INITIAL)
DOB
DATE
SEX
General instructions - All orders for clinical exams or tests must include a statement of medical necessity by ICD –9/10 code or
M
F
diagnosis. Test not covered by that code may be charged to the patient. Please check the box next to the appropriate exam and code
and write ICD 9/10 code is space provided at bottom of the form. Please read and check the contrast statement located below.
Pt. SSN
Referring Physicians Signature
ORDERS VALID FOR 30 DAYS FROM DATE OF SIGNING
Please use ALL Pre-Cert Codes for insurance pre-certifications
ALLOW USE OF CONTRAST AT THE DISCRETION OF THE RADIOLOGIST
CAT SCAN
EXAM
CONTRAST USED AT
THE DISCRETION OF
THE RADIOLOGIST
70450/70460/70470
70450/70460/70470
70486/70487/70488
70480/70481/70482
70486/70487/70488
CONTRAST USED AT
THE DISCRETION OF
THE RADIOLOGIST
EXAM
PRE-CERT CODES
HEAD
BRAIN
FACE
ORBIT
IAC
MRI
_
_
EXTREMITY SPECIFY ____________________
UPPER
73200/73201/73202
LOWER
73700/73701/73702
NECK
70490/70491/70492
CHEST
71250/71260/71270
ABD / PELVIS 74176,74177,74178
STONE PROT 74176
PELVIS (ORTHO)72192/72193/72194
SPINE
CERVICAL 72125/72126/72127
THORACIC 72128/72129/72130
LUMBAR
72131/72132/72133
CTA STUDY OF;
PRE-CERT CODES
BRAIN
IAC
ORBIT
PITUITARY
SPINE
CERVICAL
THORACIC
LUMBAR
NECK
PELVIS
EXT. UPPER-SPECIFY_
70551/70552/70553
70553
70540/70542/70543
70553
72141/72142/72156
72146/72147/72148
72148/72149/72158
70543
72195/72196/72197
73218/73219/73220
UPPER-JOINT SPECIFY 73221/73222/73223
______________
EXT. LOWER-SPECIFY
73718/73719/73720
LOWER JOINT SPECIFY 73721/73722/73723
BREAST
BREAST
LEFT
RIGHT
BILATERAL
77058
77059
YES
NO
ULTRASOUND
NUCLEAR MED
EXAM
EXAM
PRE-CERT CODES
RUQ
76705
ABDOMEN
76700
RENAL
76775
PELVIS
76856
OB-COMPLETE >14WKS
76805
OB-LIMITTED
76815
OB-F/U
76816
BIO – PROFILE
76818
PELVIC/TRANSVAGINAL 76830-76857
CAROTID
BILAT
93880
VENOUS Doppler: Bilat 93970/Uni 93971
Upper
Lower
ART. Doppler:Upper Bilat 93930 Uni 93931
Lower Bilat 93925 Uni 92926
BREAST
RT
76645
LT
76645
SCROTUM 76870 w/Doppler 93975
PYLORUS
76705
BIOPSY OF
MRA--SPECIFY
BIOPSY OF:
OTHER
OTHER
CALL 522-5015 TO SCHEDULE
VASCULAR / ECHO
EXAM
OTHER
PRE-CERT CODES
CALL 522-5015 TO SCHEDULE
ANGIO
INTERVENTIONAL
PRE-CERT CODES
CARDIAC STRESS
BONE SCAN 3 PHASE
BONE SCAN SPECT
LUNG SCAN
VENT / PERF
HIDA
I 123 THYROID UPTAKE
AND SCAN
I 131 THYROID
THERAPY
I 131 WHOLE BODY
SCAN
GASTRIC EMPTYING
STUDY
PARATHYROID SCAN
SENTINEL NODE
INJECTION
WHITE BLOOD CELL
GALLIUM STUDY
MUGA STUDY
G.I.BLEED STUDY
LIVER / SPLEEN STUDY
HEMANGIOMA STUDY
MECKEL’S STUDY
RENAL STUDY
79005
78306
78264
78070
38792
78806
78804
78472
78278
78215/78216
78205/78206
78290
78700/78701
OTHER
CALL 522-5015 TO SCHEDULE
XRAY
CALL 522-5015 TO SCHEDULE
ICD 9 DIAGNOSIS
CALL 522-5039 TO SCHEDULE ALL ANGIO EXAMS
WRITE REQUESTED EXAM IN BLOCK BELOW
SEGMENTAL 93923
PPG
93965
ABI
93922
ECHO
93306
TEE
93312
CALL 522-5015 TO SCHEDULE
78452/78453
78306/78320
78306/78320
78580
78596
78223
78006
CALL 522-5015 TO SCHEDULE
CALL 522-5015 TO SCHEDULE