ß Mount Sinai ß Beth IsraeL ß NYEE ß MS West ß PACC ß Brooklyn ß St. Luke’s ß BICCC ß Kingsway ß NYHC DIAGNOSTIC IMAGING Patient Name/DOB:____________________________________ Physician Requester: ___________________________________ Date & Signature: _____________________________________ Requester Phone: _____________________________________ Requester NPI: _______________________________________ Appointment Date/Time: _______________________________ Ins Authorization Number(s): ____________________________ ProceDure: Specific exam/area of concern: ß CT/CTA ____________________________ ß MRI/MRA ____________________________ ß Mammography ____________________________ ß X-Ray ____________________________ ß Fluoroscopy ____________________________ ß UltrasounD ____________________________ ß Nuclear MeDicine ____________________________ ß Bone Densitometry ____________________________ ß InterventionaL ____________________________ ß Other ____________________________ Signs & Symptoms: Contrast: _________________________________________ ß with ß without _________________________________________ ß with & without _________________________________________ SenD images (CD): _________________________________________ ß yes SITE ADDRESS SCHEDULING FAX -One Gustave L. Levy Place 212-241-8333 MRI/CT 212-348-7403 MRI/CT Box 1141 212-241-8333 XR/US 212-348-7403 XR/US The Mount Sinai New York, NY 10029 212-241-8333 Mammo 212-241-8333 Mammo Hospital (MSH) -1190 5th Ave 212-241-7775 PET/CT 212-831-2851 PET/CT New York, NY 10029 212-241-6611 Nuclear 212-289-2976 Nuclear 212-523-7035 XR/US 212-523-8329 XR/US 1000 Tenth Avenue 212-523-7171 NM 212-523-8890 NM Mount Sinai West 4th Floor 212-523-8320 MRI 212-523-8322 MRI (MSW) New York, NY 10019 212-523-7070 CT 212-523-7061 CT 212-523-7257 IR 212-523-8145 IR 212-523-4280 MRI 212-523-5379 MRI 212-523-4230 CT 212-523-4598 CT 1111 Amsterdam Avenue 212-523-4272 XR/BD 212-523-3798 XR/BD Mount Sinai St. Luke’s 3rd Floor, Clark Building 212-523-4244 US 212-523-2981 US (MSSL) New York, NY 10025 212-523-3400 NM 212-523-3949 NM 212-523-4446 IR 212-523-4436 IR 212-523-4267 Mammo 212-523-2888 Mammo Mount Sinai Brooklyn 3201 Kings Highway 718-951-2930 718-951-2718 (MSB) Brooklyn, NY 11234 Mount Sinai Kingsway 3131 Kings Highway 718-758-1500 718-758-2400 (KW) Brooklyn, NY 11234 Mount Sinai Beth Israel First Avenue at 16th Street 212-844-8880 Main 212-844-6815 Main Main Hospital (Petrie) New York, NY 10003 212-420-2509 IR 212-844-1098 IR 343 East 17th Street 17th Street Outpatient (off 1st Avenue) 212-844-8880 212-844-4502 MRI (17th) New York, NY 10003 10 Union Square East Phillips Ambulatory 3rd Floor, Suite 3P 212-844-8880 212-844-4502 Care Center (PACC) New York, NY 10003 Cancer Center West 325 West 15th Street 212-604-6009 212-367-1751 (BICCC) New York, NY 10011 212-604-6050 212-367-1705 55 East 34th Street New York Healthcare (b/w Park & Madison) 212-252-6004 212-252-6021 Radiology (NYHC) New York, NY 10016 New York Eye and Ear 310 East 14th Street Infirmary of Mount 212-979-4397 212-353-5927 New York, NY 10003 Sinai (NYEE) NPI: 11-0498291-7 NPI: 1174689665 NPI: 1942543889 TAX ID: SLR 13-2997301 NPI: 1851565543 TAX ID: 13-5564934 TAX ID: 800886397 MSW (West) TAX ID: 13-5564934 MSB (Brooklyn) MSH (Mount Sinai, NPI: 14-7795800-7 MSBI (PACC, Petrie and NPI: 12-45251222 Kingsway, NYHC) TAX ID: SLR 13-2997301 BICCC) TAX ID: 13-5562304 MSSL (St. Luke’s) (New York Eye & Ear) .