[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-288915-105":53,"doc-detail-288915-en":127},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":120,"head_meta":122,"extra_data":124,"updated_unix":126},105,"en","diagnostic-imaging-regional-services-required-order-information","Diagnostic Imaging Regional Services - Required Order Information","","Diagnostic imaging order form for regional services, structured to collect required patient and physician information, including legal name, date of birth, phone, gender, insurance details, referring physician and signature, contact information, CPT and ICD-10 codes, reason for exam, and order priority. The form also includes selections for multiple imaging modalities such as MRI/MRA, CT, ultrasound, nuclear medicine, breast imaging, PET/SPECT/CT options, and interventional procedures, plus authorization for additional tests and space for additional comments.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/diagnostic-imaging-regional-services-required-order-information/288915/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/diagnostic-imaging-regional-services-required-order-information/288915.png","ImageObject",442,249,{"name":88,"@type":89},"Theodora","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-12","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",9,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What information is required to complete the diagnostic imaging order?","Question",{"text":109,"@type":110},"The form requests patient legal name, date of birth, phone, gender, insurance name and member/policy/ID, physician name and NPI, physician signature with date/time, phone and fax, CPT code, ICD-10, and the reason for exam, plus order priority.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"How are imaging modalities selected on the form?",{"text":114,"@type":110},"Use the modality sections to indicate the requested study type and relevant options (such as contrast selection for MRI, CT body regions, ultrasound scope, and nuclear medicine study types).",{"name":116,"@type":107,"acceptedAnswer":117},"Is authorization for additional breast-related tests required?",{"text":118,"@type":110},"For diagnostic mammography, breast ultrasound, and/or breast biopsy, the form includes a question asking whether the patient authorizes additional tests as indicated by the radiologist, with YES or NO selections.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},288915,1790640356,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":9},687197207919,"https://ap-avatar.wpscdn.com/avatar/a000253d6f5f7c60be?x-image-process=image/resize,m_fixed,w_180,h_180&k=1779446848396160552","DIAGNOSTIC IMAGING Regional Services  \nTODAY’S DATE  \n\n| REQUIRED O R D E R INFORMATION | PATIENT LEGAL NAME |  |  | DATE OF BIRTH |  | PATIENT PHONE |  |  | GENDER |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n|  | INSURANCE NAME | MEMBER/ POLICY/ ID\\# |  |  |  |  |  | PRE-AUTHORIZATION \\# |  |  |\n|  | PHYSICIAN NAME | PHYSICIAN SIGNATURE DATE TIME |  |  |  |  |  | PHYSICIAN NPI |  |  |\n|  | PHYSICIAN/CLINIC ADDRESS |  |  |  |  |  |  |  |  |  |\n|  | CPT CODE | ICD 10 |  |  |  |  |  |  |  |  |\n|  | REASON FOR EXAM |  |  |  |  |  |  |  |  |  |\n|  | DIRECT PHYSICIAN CONTACT |  | PHONE |  |  |  | FAX |  |  | ORDER PRIORITY\u003Cbr> ROUTINE\u003Cbr> STAT |\n|  | ADDITIONAL ORDER INSTRUCTIONS |  |  |  |  |  |  |  |  |  |\n| MRI\u003Cbr> Brain  Thoracic Spine\u003Cbr> MRA Brain  Lumbar Spine\u003Cbr> MRA Neck  Abdomen\u003Cbr> Soft Tissue Neck  MRA Abdomen\u003Cbr> Cervical Spine  Pelvis\u003Cbr> Other (specify)  \u003Cbr> Shoulder  L  R\u003Cbr> Elbow  L  R\u003Cbr> Wrist  L  R\u003Cbr> Upper Extremity Non-Joint (specify)\u003Cbr> Hip  L  R\u003Cbr> Knee  L  R\u003Cbr> Ankle  L  R\u003Cbr> Lower Extremity Non-Joint (specify)\u003Cbr> Without Contrast\u003Cbr> With and Without Contrast\u003Cbr> Arthrogram  L  R\u003Cbr> Fluoro Joint Injection |  | Radiology\u003Cbr> Esophagram\u003Cbr> Upper G. I.\u003Cbr> Small Bowel Follow Through\u003Cbr> Fluoro Joint Injection\u003Cbr> Barium Enema\u003Cbr> Chest X-Ray (PA/lateral)\u003Cbr> Ribs  L  R\u003Cbr> Shoulder  L  R\u003Cbr> Humerus  L  R\u003Cbr> Elbow  L  R\u003Cbr> Forearm  L  R\u003Cbr> Wrist  L  R\u003Cbr> Hand  L  R\u003Cbr> Finger  L  R\u003Cbr> Cervical Spine\u003Cbr> Thoracic Spine\u003Cbr> Lumbar Spine\u003Cbr> Abdomen Supine\u003Cbr> Abdomen Supine & Upright\u003Cbr> Pelvis\u003Cbr> Femur  L  R\u003Cbr> Hip (includes pelvis)  L  R\u003Cbr> Knee  L  R\u003Cbr> Tibia/Fibula  L  R\u003Cbr> Ankle  L  R\u003Cbr> Foot  L  R\u003Cbr> Toe  L  R\u003Cbr> Other (specify)   |  |  | Nuclear Medicine\u003Cbr>Cardiac  Myocardial Perfusion Imaging Patient’s Weight   Height  \u003Cbr> Treadmill  Pharmacological Stress\u003Cbr> MUGA\u003Cbr>Bone Scan  Whole Body  SPECT/CT  SPECT  Multiple\u003Cbr>Area   PET/CT  Skull base to mid thigh (oncology)\u003Cbr> Whole Body Head Cardiac Viability Thyroid  Uptake/Scan  Whole Body  Therapy Hepatobiliary  with EF  without EF\u003Cbr>Gastric Emptying  Solid  Liquid\u003Cbr> Solid and Liquid\u003Cbr>Sentinel Node  Breast  L  R  Melanoma\u003Cbr>Area   Renal  Baseline  Lasix  ACE Inhibitor\u003Cbr> Other (specify)   |  |  |  |  |  |\n|  |  |  |  |  | Breast Imaging\u003Cbr> Screening Mammogram (no signs or symptoms)\u003Cbr> Diagnostic Mammogram  L  R\u003Cbr> Ultrasound if indicated\u003Cbr> Breast Ultrasound  L  R\u003Cbr> Diagnostic Mammogram if indicated\u003Cbr> Axilla  L  R\u003Cbr> Breast MRI  L  R  Localization  Scout®  Seed  Wire  L  R\u003Cbr> Mammography\u003Cbr> Ultrasound  MRI\u003Cbr> US Axillary Lymph Node\u003Cbr> Biopsy  L  R\u003Cbr> Mammography\u003Cbr> Ultrasound  MRI\u003Cbr> Cyst Aspiration  L  R\u003Cbr> Other  \u003Cbr>Do you authorize additional tests as indicated by the radiologist for diagnostic mammography, breast US and/or breast biopsy?\u003Cbr> YES  NO\u003Cbr>\u003Cbr>Diagram must be completed for all signs/symptoms |  |  |  |  |  |\n| CT\u003Cbr> Head  Chest\u003Cbr> Sinus  Abdomen\u003Cbr> Soft Tissue Neck  Pelvis\u003Cbr> Cervical Spine  Abdomen/Pelvis\u003Cbr> Thoracic Spine  Chest/Abdomen/Pelvis\u003Cbr> Lumbar Spine  Add 3D Images\u003Cbr> Urogram  CT Myelogram\u003Cbr> Renal Stone  Fluoro Joint Injection\u003Cbr> Angio  CTArthrogram  L  R    Fluoro Joint Injection\u003Cbr> Other (specify)   |  |  |  |  |  |  |  |  |  |  |\n|  |  | Additional Comments |  |  |  |  |  |  |  |  |\n| Ultrasound\u003Cbr> Abdomen Complete\u003Cbr> Abdomen Limited\u003Cbr> Soft Tissue, body part:  \u003Cbr> Aorta only  Appendix\u003Cbr> Renal\u003Cbr> Pelvis  Pulse Wave Doppler if indicated\u003Cbr> With Transvaginal  Without Transvaginal\u003Cbr> OB:  > 14 weeks  \u003C 14 weeks\u003Cbr> Scrotal  Pulse Wave Doppler if indicated\u003Cbr> Thyroid  Lymph node mapping\u003Cbr> Other (specify)   |  |  |  |  |  |  |  |  |  |  |\n|  |  | lnterventional Radiology |  |  |  |  |  |  |  |  |\n| Bone Densitometry (DEXA)\u003Cbr> DEXA Routine Screening (to include forearm if needed)\u003Cbr> DEXA Routine Screening with Appendicular Skeleton (forearm)\u003Cbr> DEXA Routine Screening with Vertebral Fracture Assessment\u003Cbr> DEXA Appendicular Ske","cbCaikzYTQfuilft","https://ap.wps.com/l/cbCaikzYTQfuilft","pdf",132063,"English","# Required order information\n## Patient, insurance, and physician details\n## Exam selections by modality\n## Breast imaging and authorization\n## Additional comments and site information","[{\"question\":\"What information is required to complete the diagnostic imaging order?\",\"answer\":\"The form requests patient legal name, date of birth, phone, gender, insurance name and member/policy/ID, physician name and NPI, physician signature with date/time, phone and fax, CPT code, ICD-10, and the reason for exam, plus order priority.\"},{\"question\":\"How are imaging modalities selected on the form?\",\"answer\":\"Use the modality sections to indicate the requested study type and relevant options (such as contrast selection for MRI, CT body regions, ultrasound scope, and nuclear medicine study types).\"},{\"question\":\"Is authorization for additional breast-related tests required?\",\"answer\":\"For diagnostic mammography, breast ultrasound, and/or breast biopsy, the form includes a question asking whether the patient authorizes additional tests as indicated by the radiologist, with YES or NO selections.\"}]","Diagnostic Imaging Regional Services - Required Order Information | PDF",1789634210]