Dmc Form Ps-1047 - Vascular Ultrasound Order Form printable pdf download

Patient Information (required for scheduling)

Patient Name: _________________________________ DOB: _________________ Sex: ❑ M ❑ F SS#: XXX-XX- ___________

First & Last Name

Patient's Address: _________________________________ __________________________ ______________ _________________

Street

City

State

Zip Code

Home Phone#: _________________ Mobile Phone #: ___________________ Email Address: ___________________________

Primary Insurance: __________________________ Policy #: ______________ Group #: __________ Phone #: ______________

Plan & Product

Secondary Insurance: _______________________ Policy #: ______________ Group #: __________ Phone #: ______________

Plan & Product

order Information - Vascular ultrasound

___________________________________

Diagnosis: ____________________________________________________________ ICD-CM Code:

Test/Service: __________________________________________________________ Appointment Date: _______________ Time: ______________

Please check appropriate box(es):

cerebrovascular evaluation:

❑ carotid / Vertebral artery duplex (93880)

Peripheral Venous evaluations:

❑ lower extremity Venous duplex and Iliocaval duplex – Duplex of the iliocaval, femoropopliteal, tibioperoneal & great

saphenous veins. Complete bilateral study. (93970)

❑ lower extremity Venous duplex + Iliocaval duplex Prn – Iliocaval segments examined based on abnormal test results,

significant risk factors, or clinical concern of PE. Complete bilateral study. (93970)

❑ lower extremity Venous duplex only – Duplex of the femoropopliteal, tibioperoneal, & great saphenous veins. Complete

bilateral study. (93970)

❑ lower extremity Venous duplex unilateral study (93971) ❑ rt

❑ lt

❑ upper extremity Venous examination Bilateral – Duplex of the IJV, Subclavian, Axillary, and are veins (93970)

❑ upper extremity Venous duplex unilateral study (93971) ❑ rt

❑ lt

Peripheral arterial evaluations:

❑ lower extremity arterial examination (93924)

-Physiologic testing (Segmental Pressures, Exercise Testing, ABI’s)

-Duplex: Aortoiliac & femoropopliteal prn (Abnormal physiologic test/patient not able to tolerate exercise test)

❑ upper extremity arterial examination – Physiologic testing and imaging (93923)

❑ specialized upper extremity evaluations – Physiologic Testing

❑ thoracic outlet (93923)

❑ Raynaud’s Phenomenon (93923)

dialysis / Vascular access site evaluations:

❑ Pre-op dialysis access site evaluation – Duplex & Physiologic Testing (93970)

❑ dialysis access site evaluation – Duplex with Physiologic Testing prn (93990)

abdominal Vascular evaluations – Duplex

❑ renal artery (93975)

❑ mesenteric (93975)

❑ abdominal aortic aneurysm (93978)

other: _______________________________________________________________________________________________________________________

special Instructions: ________________________________________________________________________________________________________

referring Physician Information

Physician Name (first & last): _______________________________________ NPI#: _________________________ GA License#: ____________________________

Physician Address: _________________________________________________ Phone#: ___________________________ Fax #: ______________________________

I herby certify that the services in the above order form are medically necessary.

Physician Signature: _____________________________________________________________________ Date: ______________

Time: _______________

Fax Orders to: 404.501.1743

Phone: 404.501.2660

Vascular ultrasound

order Form

DMC FORM # PS-1047 (03/18/15)

Dmc Form Ps-1047 - Vascular Ultrasound Order Form

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