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: _____________________________________________________ Patient: _____________________________________________________Last Name First Name Today's Date: ____________________________________________ (MM/DD/YYYY) Date of Birth: ______________________________________Last Name First Name(MM/DD/YYYY) Referring Physician: __________________________________________________ DatePatient of Birth:Phone: ______________________________________ _______________________________________________(MM/DD/YYYY) Physician Phone: ____________________________________________________ Patient Phone: _______________________________________________ FAX #: _____________________________________________________________ Insurance Company: __________________________________ q Private Pay InsuranceInsurance Company:ID #: ________________________________________________ __________________________________ 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. #: _______________________ AUC _______ CDSM_______ ________________________________________________________________ Insurance Auth. #: _______________________ AUC _______ CDSM_______ q AUTHORIZATION ASSIST, MUST FAX INSURANCE CDSM Ref #______________ ________________________________________________________________ q AUTHORIZATIONCARD & CHART NOTES ASSIST, (Excluding MUST FAX HMO) INSURANCE CARD & CHART NOTES qq STATSTAT (Referring(Referring officeoffice mustmust obtainobtain authorizationauthorization ifif required)required) X-ray (Walk-In Only) MRI MRA MRI ARTHROGRAM Body Region: _______________ # of Views: ____________________________ *If with Eovist 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 ______Biopsy q Left q Right q Bilateral q Weight Bearing Creatinine Level: ________________ Date Drawn: ___________ (MM/DD/YYYY) PICCInterventional L Radiology Pain Management CT Arthrogram q Interventional Radiology Consult CT CTA (Angiogram) CT MYELOGRAM Body Region:___________________ Cardiac CTA q Limb Salvage (Claudication, Critical Limb Ischemia) q Steroid Injection *If with contrast and over 70 years old, diabetic or renal insufficiency need GFR q Women's Health (Fibroids, Pelvic Congestion) Joint: ________________ Body Region: _________________________________________ q Men's Health (Benign Prostate Hyperplasia (BPH) Varicocele) q Aspiration q Left q Right q Back Pain (Kyphoplasty) Joint: ________________ ¦ With & Without Contrast ¦ Without (No) Contrast ¦ With Contrast q Image Guided Biopsy q Small Bowel q Foraminal Block Creatinine Level: _______________________ q Paracentesis (Abdomen) q Renal Stone Protocol Level: ________________ Date Drawn: _____________________ (MM/DD/YYYY) q Thoracentesis (Chest) q Coronary Calcium Score PICC Line q Facet Block q Lung Cancer Screening (71271) *Lung Cancer Screening Form Required q Placement q Removal Level: ________________ Port PET/CT q Epidural Injection(s) q Placement q Removal Tumor Imaging q FDG Skull Base to Mid-Thigh (78815) Level: ________________ q Other: ______________________________ q FDG Whole Body (Melanoma/Sarcoma) (78816) q Ga-68 Dotatate Neuroendocrine Tumor Ultrasound General and Vascular Brain Imaging q Brain Scan w/FDG (78608) ¦ Abdominal Complete ¦ Abdominal Right Upper Quadrant q Brain Scan w/Amyloid (78608) ¦ Abdominal Limited (For focal pain, lump, abdominal hernia and appendix) ¦ Other ________ Metastatic Imaging q Prostate Scan/Fluciclovine F-18 (Axumin) (78815) ¦ Kidneys with Bladder ¦ Soft tissue location of mass or lump ________ q WB Bone Scan w/F-18 Sodium Flouride (78816) ¦ ¦ q Cerianna (78815) Estrogen-receptor positive lesions Bladder Only Thyroid in recurrent or metastatic breast cancer ¦ Pelvic with Transvaginal ¦ Thyroid FNA Nuclear Medicine ¦ Transvaginal Only ¦ Head and Neck ¦ Pelvic Without (No) Transvaginal ¦ Testicular/Scrotum with Doppler Bone Scan q Biliary Scan with Ejection Fraction ¦ Pelvic Male (Bladder, prostrate measurement, hernia or focal area of pain) q Limited (78300) * ¦ OB (EDD: ____________) q Less than 14 weeks q Greater than 14 weeks q Follow-up needed q Whole Body (78306) Thyroid Scan q Transvaginal, if need to evaluate IUP or cvx q 3-Phase (78315)* q TC-99M Thyroid Scan Only (78013) q Vascular - Venous Vascular - Arterial q SPECT (78320)* Single 24 Hour Uptake and Scan (78014) q Multiple 4 and 24 Hour Uptake and Scan (78014) LEGS q DVT q Venous Reflux ¦ Carotid Duplex Arterial bilateral Brain Scan ¦ MUGA (78472) q Left q Right q Bilateal ¦ Renal arterial doppler q Brain DaTScan ¦ Renogram with Lasix ARMS ¦ Screening AAA WBC Scan ¦ Parathyroid Scan with SPECT q Left q Right q Bilateral ¦ Arterial Bilateral Legs with ABI 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 q Left q Right q Bilateral (Cancer Screening) ¦ 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 Stereotactic Biopsy q Ultrasound Cyst Apiration q Left q Right q Bilateral q Left q Right q Bilateral q Hookwire Localization ¦ Other: ________________________________________ 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) 7 San Diego (Alvarado) 5 1000 Vale Terrace Drive 6386 Alvarado Court, Ste 121 Oceanside Vista, CA 92084 San Diego, CA 92120 1 2 15 Oceanside (Tri-City) 8 Hillcrest 2 78 3601 Vista Way, Bldg A, Ste 101 150 W. Washington Street Oceanside, CA 92056 San Diego, CA 92103 Encinitas 3 Encinitas 9 Logan Heights (X-ray/Ultrasound Only) 3 1809 National Avenue, Ste 2104 5 477 N. El Camino Real, Bldg A, Ste 102 Pacific Ocean 4 Encinitas, CA 92024 San Diego, CA 92113 56 Poway 15 4 Poway 10 National City (MRI/Mammography/Ultrasound Only) 2427 Transportation Avenue 805 12620 Monte Vista Road, Ste A La Jolla 5 52 Poway, CA 92064 National City, CA 91950 6 125 8 Chula Vista (South Bay) 5 La Jolla (Golden Triangle) 11 163 7 4150 Regents Park Row, Ste 195 333 H Street, Ste 1095 San Diego 8 Chula Vista, CA 91910 La Jolla, CA 92037 9 805 10 6 Kearny Mesa (MRI Services Only) Chula Vista 3939 Ruffin Road, Ste 102 San Diego, CA 92123 1110 Note: Walk-in X-ray services are available at all locations, excluding Vista, Kearny Mesa, and National City. Please visit imaginghealthcare.com/xray for X-ray hours. Please bring this form to your appointment. T 858 658 6500 myihsonline.com imaginghealthcare.com.