Providence St. Peter Hospital Diagnostic Imaging Department - Completed Order Form - Fax Completed Order to 360-493-5236

Sep 19, 2026

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Completed diagnostic imaging order form for Providence St. Peter Hospital Diagnostic Imaging Department, including fax submission instructions and patient/orderer fields. Collects patient demographics, ordering physician/provider details, signs and symptoms (ICD DX code), exam selection, scheduling/contact information, results routing, and prior-exam and study preparation requirements. Lists exam categories with CPT codes such as radiology, CT, MRI/MRA, ultrasound, ultrasound OB/GYN, spine/pelvis, nuclear medicine, arterial/venous Doppler, and CTA options. Provides preparation guidance for radiology and ultrasound procedures.

LanguageEnglish

CategoryForms

FormatPDF

Pages3

Reading Time1 min

AccessFree to download

Patient Order Information

Patient details and ordering physician

Exam selection and scheduling fields

Additional information for scheduled studies

Imaging Exam Categories (with CPT codes)

Head and neck

Extremities

Cat scan and MRI/MRA

Ultrasound and OB/GYN

Spine/pelvis and urology

Gastro/fluoro and CT angiography

Doppler studies

Nuclear medicine options

Department Contact and Exam Preparations

Scheduling office contact and arrival guidance

Radiology preparation

Ultrasound preparation

| FAX COMPLETED ORDER TO 360-493-5236 | | | | | | --- | --- | --- | --- | --- | | PATIENT DATE OF BIRTH: / /
PATIENT’S FULL LEGAL NAME (LAST, FIRST, MIDDLE): ORDERING PHYSICIAN / PROVIDER (Please Print): SIGNS AND SYMPTOMS (ICD DXcode):
____________________________________________________________________________________________
Exam(s) ordered or pick from lists below:
* L.I.P. Signature: TODAY’S DATE: / / TIME:
* If Doctor requests DI to call and schedule the patient , the following information is required: Patient Phone Number: Insurance: Authorization \#: RESULTS ROUTING: Send CD Patient to return with CD
Phone report \#: Fax report \#: Additional Reports To:
ADDITIONAL INFORMATION FOR SCHEDULED STUDIES
Relating Prior Exam?: Yes No - If Yes, where? Recent Labs required for all contrast studies; i.e. CT’s, MRI’s, Angiograms, for patients 60 and over
• Creatinine (fax copy with order): Date Drawn: / /
• Does patient take Glucophage® or Metformin? Yes No
• Does patient have known IV contrast allergy? Yes No
• Patients weight: (required for NM, CT’s, MRI’s and interventional studies)
| | | | | | HEAD AND NECK CPT
Facial 3v 70150 | EXTREMITIES CPT
AC Joints Bil. 73050 | CAT SCAN CPT
Abd w/o 74150 | ULTRASOUND CPT
GENERAL | MRI / MRA CPT
Abd w/o (MRCP) 74181 | | Mandible 4v+ 70110 | Clavicle 73000 | Abd w 74160 | Abdomen 76700 | Abdomen w / w/o 74183 | | Nasal Bones 3v+ 70160 | Shoulder 2v+ 73030 | Abd w / w/o 74170 | Abd. Ltd.-RUQ/GB 76705 | Abd. MRAw / w/o 74185 | | Orbits 4v+ 70200 | Humerus 2v+ 73060 | Abd / Pel. w/o 74176 | Appendix 76705 | Pelvis w/o 72195 | | Sinus 3v+ 70220 | Elbow 2v 73070 | Abd / Pel. w 74177 | Echocardiogram with | Pelvis w / wo 72197 | | Sinus 1-2v 70210 | Elbow 3v+ 73080 | Abd / Pel. w / w/o 74178 | Definity if indicated 93307 | Brain wo 70551 | | Skull 4v+ 70260 | Forearm 2v 73090 | Cervical w/o 72125 | Guidance 76942 | Brain w / w/o 70553 | | SFT Neck 70360 | Wrist 3v+ 73110 | Chest w/o 71250 | Renal 76770 | Brain MRA w/o 70544 | | CHEST / ABDOMEN
Chest 1v 71010
Chest 2v 71020
Ribs Unil 2v 71100
Ribs Bil 3v 71110
Abd. (KUB) 1v 74000
Abd. 2v 74020
Acute Abd. 1v CXR74022 | Hand 3v+ 73130 | Chest w 71260 | Testicular 76870 | Neck MRAw / w/o 70549 | | | Fingers 2v+ 73140 | Chest w / w/o 71270 | Thyroid / Neck 76536 | C-Spine w/o 72141 | | | Hip 2v+ 73510 | Head w/o 70450 | OB / GYN | C-Spine w / w/o 72156 | | | Femur 2v 73550 | Head w / w/o 70470 | Biophysical Profile 76819 | T-Spine w/o 72146 | | | Knee 1-2v 73560 | KUB (stones) 74150 | Obstetrical 76805 | T-Spine w / w/o 72157 | | | Tibia Fibula 2v 73590 | Lumbar w/o 72131 | OB w/TVS 76805 | L-Spine wo 72148 | | | Ankle 3v+ 73610 | Maxillofacial w/o 70486 | + 76817 | L-Spine w / w/o 72158 | | | Foot 3v+ 73630 | Orbits w/o 70480 | Pelvis w/TVS 76856 | Extremities w/ jnt w/o | | | Toes 2v+ 73660 | Pelvis w/o 72192 | + 76830 | Hip/knee/ankle 73721 | | SPINE / PELVIS | Infant Lower Ext.73592 | Pelvis w 72193 | Arterial Doppler: | Shoulder,wrist 73221 | | Cervical 2 or 3v 72040 | UROLOGY | Pelvis w / w/o 72194 | Carotid Duplex 93880 | Extremities w/jnt w/cont | | Lumbar 2 or 3v 72100
Pelvis 1 or 2v 72170
Sacrum/Coccyx 72220
SI Joints 2v 72200
T-L Junction 72080
Thoracic 2v 72070
Epi Cerv / Thor 62310
Epi Lumb / Sac 62311
Facet Cerv / Thor 64490
Facet Lumb / Sac 64493
Nerve Root C-T 64479 | VCUG 74455
GASTRO / FLUORO
Be Enema 74270
Be w/air 74280
Dysphagia 74230
Esoph 74220
Small Bowel 74250
UGI 74240
UGI w/SB 74245 | Sinuses 70486
Sinus Ltd. 70486-52
ST Neck w/o 70490
Temporal Bones 70480
Thoracic w/o 72128
CTA’s
Abd. 74175
[Abd. w/ Ext. run 75635](Abd. w/ Ext. run 75635)
Chest 71275
Head 70496
Neck 70498 | mesenteric Art. 9397

FAQs

Where should the completed order be faxed?

Fax the completed order to 360-493-5236, as indicated on the form.

What information is required for the scheduled study section?

The form requests prior-exam relation details, recent labs for contrast studies, creatinine date and faxed copy, medication/contrast allergy status, and patient weight for specified exams.

How should patients prepare for radiology and ultrasound procedures?

The form lists exam-specific preparation steps such as fasting timeframes, fluids restrictions, and special instructions for ultrasound (e.g., water intake for renal ultrasound) and other listed radiology procedures.

Sep 19, 2026

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