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  GA License \\#:   Physician Address:   Phone \\#:   Fax \\#:    \nI hereby certify that the services indicated in the above order form are medically necessary.  \nPhysician Signature:   Date:   Time:    \nDM Form \\#0000 (Rev. 7/2014)  \n\n| Cat Scan (CT) |  |\n| --- | --- |\n| Head / Face / Neck\u003Cbr>􀂉 CT Head 􀂉 W/O (70450)\u003Cbr>􀂉 CTA Head (70496)\u003Cbr>􀂉 Maxillofacial w/o (70486)\u003Cbr>􀂉 Soft tissue neck with (70491)\u003Cbr>CT Chest:\u003Cbr>􀂉 Chest 􀂉with (71260)\u003Cbr>􀂉 PE Protocol (71275) | 􀂉 W & W/O (70470)\u003Cbr>􀂉 CT Sinus w/o (70486)\u003Cbr>􀂉Temporal (70480)\u003Cbr>􀂉 CTA Neck (70498)\u003Cbr>􀂉 Without (71250) |\n| 􀂉 Hi Resolution Chest w/o (71250)\u003Cbr>􀂉 Low Dose Lung 􀂉 Cardiac/Calcium Scoring (75571)\u003Cbr>CT Abdomen / Pelvis:\u003Cbr>􀂉 Abdomen 􀂉With (74160) 􀂉 Without (74150)\u003Cbr>􀂉 Abdomen & Pelvis 􀂉with (74177) 􀂉 Without (74176)\u003Cbr>􀂉 Pelvis 􀂉With (72193) 􀂉 Without (72192)\u003Cbr>􀂉 CTA Abdomen and Pelvis with (74174)\u003Cbr>Abdomen / Pelvis Protocols:\u003Cbr>􀂉 Renal Stone Protocol (71476)\u003Cbr>􀂉 Pancreatic Protocol (74170)\u003Cbr>􀂉 Renal MASS Protocol (74170, 72193)\u003Cbr>􀂉 3 Phase Liver (74170)\u003Cbr>􀂉 Hematuria (74178)\u003Cbr>􀂉 CT Enterocylysis (74177)\u003Cbr>􀂉 AAA Protocol – Abdomen/Pelvis with (74174)\u003Cbr>􀂉 Dissection (Chest/Abd/Pelvis) (71275/74174)\u003Cbr>CT Spine / Extremity\u003Cbr>􀂉 Cervical w/o (72125) 􀂉 Thoracic w/o (72128)\u003Cbr>􀂉 Lumbar w/o (72131)\u003Cbr>􀂉Lower Extremity w (73701) 􀂉 Lower extremity w/o (73700)\u003Cbr>􀂉Upper Extremity w/ 􀂉 Upper Extremity w/o\u003Cbr>Specify body part:  \u003Cbr>􀂉 LEFT 􀂉 RIGHT |  |\n\n\n| Brain / Neck / Orbit\u003Cbr>􀂉 Brain\u003Cbr>􀂉 Orbit / Face / Neck\u003Cbr>􀂉 MRA/MRV Brain (70544)\u003Cbr>􀂉 IAC (70553)\u003Cbr>Spine |  |  | MRI\u003Cbr>􀂉W/O (70551) 􀂉 W& WO (70553)\u003Cbr>􀂉W/O (70540) 􀂉 W & WO (70543)\u003Cbr>􀂉 MRA Neck W & W/O (70549)\u003Cbr>􀂉 Pituitary (70553) |  |\n| --- | --- | --- | --- | --- |\n| 􀂉 Cervical spine\u003Cbr>􀂉 Thoracic spine\u003Cbr>􀂉 Lumbar Spine |  | 􀂉 W/O (72141)\u003Cbr>􀂉 W/O (72146)\u003Cbr>􀂉W/O (72148) |  | 􀂉 W & W/O (72156)\u003Cbr>􀂉 W & W/O (72157)\u003Cbr>􀂉 W & W/O (72158) |\n| Breast\u003Cbr>􀂉 Breast Bilateral with and without (77059)\u003Cbr>􀂉 Breast Biopsy (19085): \u003Cbr>Abdomen/Pelvis: |  |  |  |  |\n| 􀂉 Abdomen\u003Cbr>􀂉 Pelvis | 􀂉 WO (74181)\u003Cbr>􀂉 W/O (72195) |  |  | 􀂉 W & W/O (74183)\u003Cbr>􀂉 W & W/O (72197) |\n| 􀂉 Prostate (72197)\u003Cbr>􀂉 MRCP (74181) 􀂉 Enterography (74183,72197)\u003Cbr>Upper Extremity JOINT:  􀂉 Without (73221) 􀂉 W & WO (73223)\u003Cbr>􀂉 LEFT 􀂉 RIGHT\u003Cbr>􀂉 Shoulder 􀂉 Elbow 􀂉 Wrist\u003Cbr>Upper Extremity NON-JOINT- 􀂉 Without (73218) 􀂉 W & WO (73220)\u003Cbr>􀂉 LEFT 􀂉 RIGHT\u003Cbr>􀂉 Humerus 􀂉 Forearm 􀂉 Hand\u003Cbr>Lower Extremity JOINT:  􀂉 Without (73721) 􀂉 W & WO (73723)\u003Cbr>􀂉 LEFT 􀂉 RIGHT\u003Cbr>􀂉 Hip 􀂉 Knee 􀂉 Ankle\u003Cbr>Lower Extremity NON-JOINT- 􀂉 Without (73718) 􀂉 W & WO (73720)\u003Cbr>􀂉 LEFT 􀂉 RIGHT\u003Cbr>􀂉 Femur 􀂉 Tib-Fib 􀂉 Foot\u003Cbr>􀂉 OTHER:   CPT:   |  |  |  |  |\n\n\n| Patient Name:   DOB:   Sex: 􀂉 M 􀂉 F SS\\#: XXX-XX-  |  |\n| --- | --- |\n| Home Phone \\#:   Mobile Phone \\#:   Insurance:   Policy \\#:   Are we ruling out a specific diagnosis (specify):   ICD-   SYMPTOMS / DIAGNOSIS:   Appointment Date/Time: \u003Cbr>SPECIAL REQUEST (Please check all that apply)\u003Cbr>􀂉 STAT call report \\#:   􀂉 Send films with patient\u003Cbr>􀂉 FAX \\# (if different than AutoFAX \\#):   􀂉 CD images | |\n\n\n| Ultrasound |  |  |\n| --- | --- | --- |\n| 􀂉 Abdomen(76700)\u003Cbr>􀂉 Sonohysterogram (76831)\u003Cbr>􀂉 Thyroid (76536)\u003Cbr>􀂉 BPP (76819) | 􀂉 Abdominal wall mass (76705)\u003Cbr>􀂉 Aorta (76770)\u003Cbr>􀂉 Cervical lymph node\u003Cbr>􀂉OB follow-up (76816) | 􀂉 Renal (76705) 􀂉 Prostate (76872)\u003Cbr>􀂉 Pelvic (76856) 􀂉 Pelvic with transvaginal (76856/76830)\u003Cbr>􀂉 Testicles (76870)\u003Cbr>􀂉 OB > 14 weeks (76805) 􀂉 OB \u003C 14weeks (76801)\u003Cbr>􀂉 OB follow-up with endovaginal (76817,76816) |\n| 􀂉 OB with endovaginal \u003C14 weeks (76817,76801) |  |  |\n| Extremity: Non vascular:   Other:   CPT:   |  |  |\n\n\n|  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- |\n| |  |  |  |  | Imaging Services Scheduling Order Form\u003Cbr>FAX orders to: 404.501.1743\u003Cbr>Phone: 404.501.2660 |  |\n| \u003Cbr>Pa","cbCaiiM57wWp6NO2","https://ap.wps.com/l/cbCaiiM57wWp6NO2","pdf",308161,"English","# Patient Information\n## Physician Certification and Scheduling Details\n## CT (Cat Scan) Selections\n## MRI Selections\n## Ultrasound Selections\n## Interventional Radiology and Mammography/Breast Ultrasound","[{\"question\":\"What information is required from the physician on this order form?\",\"answer\":\"The form requires the physician name, contact details, and certification that the ordered services are medically necessary. It also includes physician signature, date, and time.\"},{\"question\":\"What types of imaging procedures can be ordered?\",\"answer\":\"CT (including head, chest, abdomen/pelvis, spine/extremity), MRI, ultrasound, interventional radiology, and mammography/breast ultrasound are covered, with selectable CPT-coded options.\"},{\"question\":\"What special requests can be indicated for the appointment?\",\"answer\":\"Special requests include STAT call report, sending films with the patient, and providing imaging as CD images, plus fax information if different from automated routing.\"}]","Imaging Services Scheduling Order Form - Fax and Phone Contact - Radiology | PDF",1789854681]