Diagnostic Imaging Referral Form
ADVERTISEMENT
1
2Diagnostic imaging RefeRRal foRm
Name of Patient
D.O.B.
Home Phone Number
Work Phone Number
Diagnosis/Signs & Symptoms (Do Not Use “Rule Out”)
Insurance Name
Referring Physician (Please PRINT)
Physician’s Signature
Primary Care Physician (Please PRINT)
Address
m
m
Fax report delivery
Call immediate verbal results/fax report to follow_____________________________
Prior authorization number(s) ________________________________________________________________________
RaDiogRaphic exams
ct scan computed tomography
q Chest
q Abdomen/KUB
q Sinuses
q Allergies to X-Ray Contrast/Dye
q Spine
q Cervical
q Thoracic
q Lumbar
q Yes, notify Center q No
q Orthopaedic
RT
LT
q Bilateral
q Brain
q Joint_______________
q Sinus
q Other______________
q Soft tissue neck
q Chest
q Abdomen (prep required)
RaDiogRaphic special exams
q Pelvis (prep required)
q Allergies to X-Ray Contrast/Dye
q Renal stone protocol
q Yes, notify Center q No
q Spine with MRP
Cervical
Thoracic
Lumbar
q Barium Swallow
q Barium Enema (prep required)
q Joint/Extremity (designate) ________RT LT q Bilateral
q Air Contrast Barium Enema (prep required)
q CT Angiography (specify area) (prep required) _________
q Upper GI Series (prep required)
______________________________________________________
q Small Bowel may take up to 4 hours (prep required)
mammogRaphY
q IVP (prep required)
q Screening Mammogram
q Arthrogram (specify joint) ________________
q Diagnostic Mammogram (requires diagnosis)/Ultrasound
q Hysterosalpingogram/HSG
if necessary
q Bone Density/Osteoporosis Study
(Refer to RAPA/St. Vincent Breast Center Worksheet specific for
q Water Soluble
diagnostic breast imaging prior to scheduling.)
q Breast Ultrasound
UltRasoUnD exams
Breast procedures – contact Breast Center for information
q Abdomen (prep required)
q Aorta (prep required)
e.g. Core biopsy, aspirations, ductogram
q Gall Bladder (prep required) q Kidneys (prep required)
pre-op localization
q Pelvis with endovaginal if necessary (prep required)
q Pregnancy (less than 14 weeks)
special seRVices anD contact nUmbeRs
q Pregnancy (greater than 14 weeks)
q EVLT for varicose veins (686-2681)
q Thyroid
q Scrotum
q Breast
q Sclerotherapy for spider veins (686-2681)
q Other ________________________
q PET scanning (552-2100)
q Vertebroplasty (552-2982)
VascUlaR UltRasoUnD
q Uterine Fibroid Embolization (552-2982)
q Carotid Doppler
q Arterial Doppler Upper Lower
q Venous Doppler Upper Lower RT LT Bilateral
RAPA employees are unable to watch unattended children. Please make provisions for childcare, if necessary,
RAPA accepts most major
prior to coming to our office for your radiologic exam.
insurance plans, including
Blue Cross Blue Shield
Please bring all insurance information to each visit.
products, Aetna, Cigna,
United Health Care and
Most major insurers will pay for radiology examinations, although some require prior authorization for certain procedures. Patients may be
QualChoice QCA. Prior
required to pay at the time of service depending on the type of insurance coverage. You should check your benefits with your insurers at
least a day before the exam.
authorization may be
Your insurance policy is a contract between you and your insurance company. As a courtesy to you, we will be glad to file your insurance
required for HITECH or
claims. Bring your insurance card with you when you come for the exam. You will be responsible for all services that are not covered by
Interventional Imaging.
your insurance.
If you have any questions about your coverage, you may call our business office at 501-664-3914 or 888-390-7272.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical