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The form includes selections for multiple anatomical areas and laterality where applicable, plus options for “w/o” and “w/ & w/o” imaging along with associated listed codes. It also provides sections for special MRI procedures such as MR Arthrogram and MR Angiogram, each with targeted body part options and predefined code sets. A diagnosis/indications area with ICD-10 codes, along with physician signature and date, supports clinical documentation and billing 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Physician Signature and Date.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},307769,1789854727,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":8,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":125,"read_time":4},5909892210082,"https://ap-avatar.wpscdn.com/avatar/56001069da27c9f41e8?x-image-process=image/resize,m_fixed,w_180,h_180&k=1789614185077863061","| Patient Information |  |\n| --- | --- |\n\nMRI IMAGING ORDER FORM  \n\n| Patient Name |  | DOB |  |\n| --- | --- | --- | --- |\n| Phone | Email |  |  |\n| Address | City | State | Zip |\n| Provider Information |  |  |  |\n| Provider Name |  | NPI |  |\n| Office Name |  |  |  |\n| Office Address | City | State | Zip |\n| Office Phone | Fax |  |  |\n\n\n| MRI |  |\n| --- | --- |\n| Abdomen Brain Bilateral Breast Cervical Spine Chest/Thorax\u003Cbr>Lower Extremity Joint\u003Cbr>􀂅 Ankle 􀂅 Hip 􀂅 Knee\u003Cbr>Lower Extremity Non-Joint\u003Cbr>􀂅 Foot 􀂅 Lower Leg 􀂅 Thigh\u003Cbr>Lumbar Spine Orbit/Face/Neck Pelvis\u003Cbr>Thoracic Spine TMJ\u003Cbr>Upper Extremity Joint\u003Cbr>􀂅 Elbow 􀂅 Shoulder 􀂅 Wrist\u003Cbr>Upper Extremity Non-Joint\u003Cbr>􀂅 Hand 􀂅 Upper Arm 􀂅 Forearm | 􀂅 w/o (74181) 􀂅 w/ & w/o (74183)\u003Cbr>􀂅 w/o (70551) 􀂅 w/ & w/o (70553)\u003Cbr>􀂅 w/o (77047) 􀂅 w/ & w/o (77049)\u003Cbr>􀂅 w/o (72141) 􀂅 w/ & w/o (72156)\u003Cbr>􀂅 w/o (71550) 􀂅 w/ & w/o (71552)\u003Cbr>􀂅 w/o (73721) 􀂅 w/ & w/o (73723)\u003Cbr>􀂅 R 􀂅 L\u003Cbr>􀂅 w/o (73718) 􀂅 w/ & w/o (73720)\u003Cbr>􀂅 R 􀂅 L\u003Cbr>􀂅 w/o (72148) 􀂅 w/ & w/o (72158)\u003Cbr>􀂅 w/o (70540) 􀂅 w/ & w/o (70543)\u003Cbr>􀂅 w/o (72195) 􀂅 w/ & w/o (72197)\u003Cbr>􀂅 w/o (72146) 􀂅 w/ & w/o (72157)\u003Cbr>􀂅 w/o (70336)\u003Cbr>􀂅 w/o (73221) 􀂅 w/ & w/o (73223)\u003Cbr>􀂅 R 􀂅 L\u003Cbr>􀂅 w/o (73218) 􀂅 w/ & w/o (73220)\u003Cbr>􀂅 R 􀂅 L |\n| Other :\u003Cbr>__________________________________________________________________ |  |\n\n\n| MR Arthogram |\n| --- |\n| 􀂅 Ankle (73722, 77002, 27648) 􀂅 R 􀂅 L\u003Cbr>􀂅 Wrist (73722, 77002, 25246) 􀂅 R 􀂅 L\u003Cbr>􀂅 Shoulder (73722, 77002, 23350) 􀂅 R 􀂅 L\u003Cbr>􀂅 Knee (73722, 77002, 27369) 􀂅 R 􀂅 L\u003Cbr>􀂅 Hip (73722, 77002, 27093) 􀂅 R 􀂅 L\u003Cbr>􀂅 Elbow (73722, 77002, 24220) 􀂅 R 􀂅 L\u003Cbr>􀂅 TMJ (70336, 77002, 21161) |\n\n\n| MR Angiogram |\n| --- |\n|  |\n| 􀂅 Abdomen (74185)\u003Cbr>􀂅 Chest/Thorax (71555)\u003Cbr>􀂅 Head w/o (70544) 􀂅 Head w/ & w/o (70546)\u003Cbr>􀂅 Lower Extremity (73725)\u003Cbr>􀂅 Ankle 􀂅 Hip 􀂅 Knee 􀂅 Foot 􀂅 Lower Leg 􀂅 Thigh 􀂅 R 􀂅 L\u003Cbr>􀂅 Neck/Carotid w/o (70547) 􀂅 Neck/Carotid w/ & w/o (70549)\u003Cbr>􀂅 Pelvis (72198)\u003Cbr>􀂅 Spine/Spinal Canal (72159)\u003Cbr>􀂅 Upper Extremity (73225)\u003Cbr>􀂅 Elbow 􀂅 Shoulder 􀂅 Wrist 􀂅 Hand 􀂅 Upper Arm 􀂅 Forearm 􀂅 R 􀂅 L |\n\nSpecial Instructions:  \n\n| Diagnosis/Indications: | ICD-10 Codes: |\n| --- | --- |\n\nPhysician Signature :   Date :","cbCaisUiIpBw6Z7J","https://ap.wps.com/l/cbCaisUiIpBw6Z7J","pdf",195714,"English","# MRI Imaging Order Form\n## Patient Information\n## Provider Information\n## MRI Study Selections\n## MR Arthrogram\n## MR Angiogram\n## Diagnosis/Indications and ICD-10\n## Physician Signature and Date","[{\"question\":\"What patient details are requested on the MRI order form?\",\"answer\":\"The form asks for patient name, date of birth (DOB), phone, email, and address details including city, state, and ZIP.\"},{\"question\":\"What provider information is included?\",\"answer\":\"It collects provider name, NPI, office name, office address, city/state/ZIP, office phone, and fax.\"},{\"question\":\"Where do physicians document diagnosis codes and sign the order?\",\"answer\":\"A Diagnosis/Indications section lists ICD-10 codes, and the order is finalized with a Physician Signature and Date.\"}]","RadiologyAssist - MRI Imaging Order Form | PDF"]