LAH IMG Order Form - ORTHO - CFO

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LAH IMG Order Form - ORTHO - CFO
Please fax this form to
303-738-2600
Medical Imaging
Last Name
For more forms call (303) 738-2680
Offering same day service (as insurance allows)
First Name
Phone
Scheduling/Pre-Auth Instructions
DOB
Alternate Phone:
SS#
Insurance
Pre-Auth # (if available)
Special Instructions
Ankle L / R
Hip L / R
Knee L / R
Shldr L / R
Wrist L / R
C-SP
T-SP
L-SP
Pelvis
Other:
contrast
w w/o
ULTRASOUND
Bil Venous Doppler
Venous Doppler L / R
NIVA Arterial
Upper L / R
Lower L / R
NIVA Venous
Upper L / R
Lower L / R
Other:
MRI
contrast
w&w/o w w/o
C-SP
T-SP
L-SP
Ankle L / R
Hip/Pelvis
Knee L / R
Shldr L / R
Wrist L / R
Arthrogram
Sedation
Orbits-pre MRI
Other:
Hip Inject L / R
Other:
LAB
Chest PA/Lat
C-SP
T-SP
L-SP
Pelvis/Hip
Neurodiagnostics
EMG
upper ext
lower ext
VQ Lung Scan & CXR
Whole Body Bone Scan
3 Phase Bone Scan
Limited Bone Scan
Spect Bone Scan
WBC Scan
Other:
FLUORO
X-RAY
Ankle L / R
Elbo L / R
Knee L / R
Shlder L / R
Wrist L / R
Other:
NUCLEAR SCAN
NCV
EEG
VEP
To schedule an appointment:
Phone: 303-738-2767
M-F 8am-6pm
Fax: 303-738-2600
Check for LAH to obtain pre-authorization
Please fax insurance card & clinical notes
*Humana Anthem BCBS. & United Healthcare
do not allow facilities to pre-auth. MD office
must obtain.
Diagnosis or Reason for Exam/ICD Code:
CT SCAN
LAH Scheduling will automatically call
any patient not already scheduled and fax
a confirmation to the physician’s office.
Other/Notes:
Special Needs:
Allergies
Can’t Lie Still
Claustrophobia
Contrast Reaction
Hearing/Language
Mental Condition
Physical Limitations
LAB: The following lab tests
will be performed as needed
per the radiologist:
Pregnancy test
BUN, Creatinine
ProTime, PPT, CBC
BUN
CMP
Timothy Lehman, MD
Creatinine
Michael Fuller, MD
Explain:
CBC
Robert J. Bess, MD
Cell Cnt
Robert L. Thomas, MD
CRP
Result Special Requests:
Ph: 303-738-2552
Crystal Analysis
STAT
Read
&
Call
CTS
Date
Send CD w/ Patient
Culture/Sensitivity
Send CD via Courier
ESR
Release Patient/Call Results Physician Signature
Gm Stain
Hold Patient/Call Results
Synovial Fluid

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