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imaging center test request

   
Patient's Name
Date of Birth
Address (City, State, Zip)
Social Security No. - -
Home Phone
Work Phone
Patient's Diagnosis
Type of Test
Insurance
Pre-cert? Yes No
Ordering Physician
Office Phone
Office Fax
   
CARDIAC IMAGING STUDIES
Echocardiography - Dx
  Doppler Echo
  Exercise Stress Echo
  Pharmacologic Stress Echo
 
   
Nuclear Cardiology - Dx
  Exercise Nuclear Stress Test *
  Pharmacologic Nuclear Stress Test *
  * All Blue Cross/Blue Shield Plans need authorization from the ordering physician.
   
Non-Imaging Stress Tests - Dx
  Treadmill Exercise STress Test
   
Holter/Event Monitoring - Dx
  Holter Monitor
  T-Wave Altemans   24-Hour Other
   
VASCULAR STUDIES
Arterial - Dx
  Lower Extremity
  Upper Extremity
  Thoracic Outlet Syndrome
 
  AVF Steal Study
  Digital Waveform
  Duplex Graft Velocity
  Vasospasm/Raynaud's   Upper Lower
   
Venous - Dx
  Venous Dopper Duplex
   Right  Left Bilateral Upper   Lower
  AV Fistula
  Vein Mapping
   
Abdominal Imaging - Dx
NPO After Midnight
  Aorta
  Messenteric/SMA
  Renals
   
Cerebrovascular - Dx
  Carotid/Vertebral
  Subclavian Steal
   Right  Left Bilateral
Lipid Screening - Dx 272.4
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