Bone Density Study-Dxa-Referral Form
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1Department of Radiology
Phone: (603) 653-9388
Please fax request to:
Referral Form
Fax: (603) 650-0380
Bone Density Study (DXA)
Today’s date: _____________________ Date of service: _________________________ Time of service: ________________
Patient’s name: ___________________________________________________________________________________________
MRN: ____________________________________________________ DOB: _________________________________________
Mailing address: ___________________________________________________________________________________________
Home phone: ______________________ Work phone: _______________________ Cell phone: _______________________
Medicare:
Primary
Secondary
Current Height: ____________
Current Weight: ____________ lbs
Date of last DXA scan: ______________________________________________________________________________________
Patient’s special needs: ____________________________________________________________________________________
Clinical history: ____________________________________________________________________________________________
_________________________________________________________________________________________________________
Pediatric indications: ________________________________________________________________________________________
_________________________________________________________________________________________________________
Requesting provider: ______________________________________________________________________________________
Office phone: _____________________________________________ Office fax: _____________________________________
Address: _________________________________________________________________________________________________
Staff physician: ___________________________________________________________________________________________
Office phone: _____________________________________________ Pager #: ______________________________________
Medicare/ non-Medicare Insurance Covered Indications
Medicare patients only: at least 24 months must have passed since the last bone mass measurement was performed.
Any sooner will need an Advanced Beneficiary Notice (ABN) signed.
All insurances including Medicare must meet one or more of the covered indications
(check all that apply):
.
A woman who is estrogen deficient or at clinical risk for osteoporosis based on medical history and other findings
A person with vertebral abnormalities on x-ray suggesting osteoporosis, low bone mass or vertebral fractures.
A person with primary hyperparathyroidism.
A person receiving (or expecting to receive) glucocorticoid (steroid) therapy equivalent to 5mg of prednisone, or
greater, per day, for more than 3 months.
A person being monitored to assess the response to FDA-approved osteoporosis drug therapy such as:
Actonel, Boniva, Fosamax, Evista, Calcimar, Calcitonin, Miacalcin
*Other indications (ABN/waiver needed): _________________________________________________________________
*If a Medicare patient does not meet at least ONE of the above indications, you MUST have a signed ABN/waiver of
payment at the time of scheduling, indicating the understanding that services may not be covered. ABN/waiver must be
signed and faxed with the request to (603) 650-0380.
Secretary: _____________________________________________________ Phone/ext: _______________________________
Requesting provider signature (required): _______________________________________________________________________
One Medical Center Drive | Lebanon, NH 03756 | Tel: (603) 650-5000 |
Rev. 1
-21-10
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