PLACE LABEL HERE
OUTPATIENT ORDER – PRECERTIFIED EXAMS
IMAGING SERVICES
Imaging Scheduling:
Phone:
Fax:
678-312-3444
678-442-9736
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 SERVICE.
Allergies: ____________________________________________________________________
Symptoms/Diagnosis (with ICD-9 codes): ______________________________________________________________________________________
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:
Bone Scan:
 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
(with correlating films if medically
necessary)
 Whole Body
 Limited
Gastric Emptying
Hepatobiliary (HIDA)
 With Pharmacological
Intervention for EF
WBC Scan (Gallium/Ceretec)
Lung Scan (V/Q)
Renal with Lasix (furosemide)
Renal with Vasotec (enalapril)
Thyroid Uptake & Scan
Other: ________________
Neuro:
 Brain
 Neck (soft tissue)
 Pituitary
 IAC
Spine:
 Cervical
 Thoracic
 Lumbar
 Sacrum-SI Joints
Abdominal:
 Abdomen
 MRCP
 Adrenals
 Kidney
 Liver
 Pelvis (Gyn–Prostate)
Musculoskeletal:
 Rt  Lt  Bilateral
 Shoulder
 Hip
 Elbow
 Knee
 Wrist
 Ankle
 Pelvis (Bony)/Hip
 Foot
 Bone:____________________
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
 _______________________
 Arthrogram (with contrast)
Site_____________________
 _______________________
 Breast:
 Rt  Lt  Bilateral
 3D Reconstruction
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)
SPECT/CT
Bone Scan
 Whole Body OR  Limited
Brain
Parathyroid
Octreoscan
Prostascint (chest/abd/pelvis)
Renal
Other:__________________
PET/CT
***Please Use Dedicated
PET/CT Order
Form # 26113***
Specify: ________________
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
 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.
*2-18693*
2
FORM 2-18693 REV. 02/2012
WHITE: Medical Record
CANARY: Physician Office
Page 1 of
PLACE LABEL HERE
OUTPATIENT ORDER – PRECERTIFIED EXAMS
IMAGING SERVICES
*2-18693*
2
FORM 2-18693 REV. 02/2012
WHITE: Medical Record
CANARY: Physician Office
Page 1 of
OUTPATIENT ORDER – PRECERTIFIED EXAMS
IMAGING
SERVICES
go to WWW.GWCIMAGING.ORG and click onto the facility where you are scheduled.
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
phone: 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 2-18693 REV. 02/2012
Page 2 of 2