docLAH 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
