Patient Scheduling: Call for Appointment Phone 858 658 6500 Espanol 858 658 6400 Order Online: Fax 866 558 4329 TAX ID: 47-3394746 myihsonline.com NPI: 149 714 8456 Patient:______Last Name First Name Today's Date:______(MM/DD/YYYY) Date of Birth:______(MM/DD/YYYY) Referring Physician: ______Patient Phone: ______Physician Phone: ______
Insurance Company: ______q Private Pay Reason for Exam and ICD-10 code: Insurance ID #: ______MUST PROVIDE SEPARATE REASON/ICD-10 FOR EACH EXAM REGION (REQUIRED) ______Insurance Auth. #: ______CDSM/AUC#______q AUTHORIZATION ASSIST, MUST FAX INSURANCE CARD & CHART NOTES q STAT (Referring office must obtain authorization if required) X-ray (Walk-In Only) MRI MRA MRI ARTHROGRAM Body Region: ______# of Views: ______*If with contrast and over 70 years old, diabetic or renal insufficiency need GFR ______q Left q Right q Bilateral q Weight Bearing Body Region: ______q Left q Right q Bilateral Body Region: ______# of Views: ______¦ With & Without Contrast ¦ Without (No) Contrast q Left q Right q Bilateral q Weight Bearing ___Prostate Imaging for Cancer with 3D Rendering (preferred) Body Region: ______# of Views: ______Screening ____Diagnostic q Left q Right q Bilateral q Weight Bearing Creatinine Level:______Date Drawn: ______(MM/DD/YYYY) Interventional Radiology Pain Management CT Arthrogram PICC L CT CTA (Angiogram) CT MYELOGRAM Cardiac CTA PICC Line Body Region:______q Placement q Removal q Steroid Injection *If with contrast and over 70 years old, diabetic or renal insufficiency need GFR ______Joint: ______Body Region: ______Portacath q Aspiration q Placement q Removal q Left q Right Joint: ______q Image Guided Biopsy ¦ With & Without Contrast ¦ Without (No) Contrast ¦ With Contrast q Foraminal Block q q Small Bowel Paracentesis (Abdomen) Level: ______Creatinine Level: ______q Facet Block q Renal Stone Protocol q Thoracentesis (Chest) Date Drawn: ______(MM/DD/YYYY) Level: ______q Coronary Calcium Score q Other: q Epidural Injection(s) q CT Colonography ______(Virtual Colonoscopy) Level: ______q Lung Cancer Screening (G0297) *Lung Cancer Screening Form Required Ultrasound General and Vascular PET/CT Tumor Imaging q FDG Skull Base to Mid-Thigh (78815) ¦ Abdominal Complete ¦ Abdominal Right Upper Quadrant q FDG Whole Body (Melanoma/Sarcoma) (78816) ¦ Abdominal Limited (For focal pain, lump, abdominal hernia and appendix) ¦ Other______q Ga-68 Dotatate Neuroendocrine Tumor ¦ Kidneys with Bladder ¦ Soft tissue location of mass or lump ______Brain Imaging q Brain Scan w/FDG (78608) ¦ Bladder Only ¦ Thyroid q Brain Scan w/Amyloid (78608) ¦ Pelvic with Transvaginal ¦ Thyroid FNA Metastatic Imaging q Prostate Scan/Fluciclovine F-18 (Axumin) (78815) ¦ Transvaginal Only ¦ Head and Neck q WB Bone Scan w/F-18 Sodium Flouride (78816) ¦ Pelvic Without (No) Transvaginal ¦ Testicular/Scrotum with Doppler Nuclear Medicine ¦ Pelvic Male (Bladder, prostrate measurement, hernia or focal area of pain) ¦ OB (EDD: ______) q Less than 14 weeks q Greater than 14 weeks q Follow-up needed q Biliary Scan with Ejection Fraction Bone Scan q Transvaginal, if need to evaluate IUP or cvx q Limited (78300) * Thyroid Scan q Whole Body (78306) Vascular - Arterial q TC-99M Thyroid Scan Only (78013) Vascular - Venous q 3-Phase (78315)* ¦ Carotid Duplex Arterial bilateral q Single 24 Hour Uptake and Scan (78014) LEGS q DVT q Venous Reflux q SPECT (78320)* ¦ Renal arterial doppler q Multiple 4 and 24 Hour Uptake and Scan (78014) q Left q Right q Bilateral Brain Scan ¦ MUGA (78472) ¦ Screening AAA q Brain DaTScan ¦ Renogram with Lasix ARMS ¦ Arterial Bilateral Legs with ABI WBC Scan ¦ Parathyroid Scan with SPECT q Left q Right q Bilateral q Limited (78800)* ¦ Other: ______HSG q Whole Body (78802) *Specify Body Region: ______¦ Hysterosalpingogram (Flouroscopy guidance) Osteoporosis Detection ¦ Saline infused Sonohysterography (SIS) (Ultrasound Guidence) Pelvic US Required q Patient has prior ultrasound on file ¦ ¦ q q q Patient needs pelvic ultrasound ordered QCT DEXA DEXA Hip & Spine (77080) DEXA Wrist (77081) Breast Imaging
Mark the clinical interest of Mammography concern in the diagram Breast MRI Breast Ultrasound q Screening q with 3-D Mammogram (Tomosynthesis) q q Diagnostic q with 3-D Mammogram (Tomsynthesis) q with contrast Targeted Ultrasound (for isolated palpable findings) q Left q Right q Bilateral (Cancer Screening) q Left q Right q Bilateral ¦ Diagnostic mammogram required with ¦ q RIGHT LEFT q without (No) contrast Lump or Mass with Ultrasound targeted ultrasound. q Left q Right (For Implant Integrity) O'clock position ______¦ Pain or Tenderness (non-cyclical) _q with Ultrasound q MRI Breast Biopsy q Left q Right q Left q Right q Bilateral Centimeters from nipple______¦ Discharge q with Ultrasound q Call back q Left q Right q Screening Complete (76641) ¦ High-Risk Breast Cancer Assessment q Ultrasound Guided Biopsy q Left q Right q Bilateral q Stereotactatic Biopsy q Ultrasound Cyst Apiration q Left q Right q Bilateral q Left q Right q Bilateral q Hookwire Localization ¦ Other: ______2020v.1_1
IHS_Referral_Form-v2-2020.indd 1 3/11/20 10:17 AM FOR ALL PATIENTS
• Payment for services is due at the time of your exam, which may include co-payments, co-insurance and/or deductibles. We accept personal checks and all major credit cards.
• To assist you in processing your insurance claims, please bring your current insurance card and photo ID to your appointment.
• Once your exam is complete, you can access your reports electronically at myihsonline.com.
Our Imaging Locations
1 Vista (Ultrasound Services Only) 6 Kearny Mesa (MRI Services Only) 1000 Vale Terrace Drive 3939 Ruffin Road, Ste 102 5 Vista, CA 92084 San Diego, CA 92123 Oceanside 1 2 15 2 Oceanside (Tri-City) 7 San Diego (Alvarado) 78 3601 Vista Way, Bldg A, Ste 101 6386 Alvarado Court, Ste 121 Oceanside, CA 92056 San Diego, CA 92120 Encinitas 3
5 3 Encinitas 8 Hillcrest Pacific Ocean 4 Poway 477 N. El Camino Real, Bldg A, Ste 102 150 W. Washington Street 56 Encinitas, CA 92024 San Diego, CA 92103 15
805 La Jolla 5 52 4 Poway 9 Logan Heights (X-ray/Ultrasound Only) 6 12620 Monte Vista Road, Ste A 1809 National Avenue, Ste 2104 125 8 163 7 Poway, CA 92064 San Diego, CA 92113 San Diego 8 9 805 5 La Jolla (Golden Triangle) 10 Chula Vista (South Bay) Chula Vista 4150 Regents Park Row, Ste 195 333 H Street, Ste 1095 Chula Vista, CA 91910 La Jolla, CA 92037 10
Note: Walk-in X-ray services are available at all locations, excluding Vista and Kearny Mesa. Please visit imaginghealthcare.com/xray for X-ray hours.
Please bring this form to your appointment.
T 858 658 6500 myihsonline.com imaginghealthcare.com
IHS_Referral_Form-v2-2020.indd 2 3/11/20 10:17 AM