Contact UsORDER MOBILE SERVICE! Get in Touch! STAT Circle & Call if Exam is STAT! General Info DATE TO BE DONE PATIENT: FIRST PATIENT: LAST ROOM# GENDER MaleFemale DATE OF BIRTH Facility Info ORDERING FACILITY: FACILITY ADDRESS: CONTACT: PHONE: FAX: ORDERING PHYSICIAN: FIRST NAME ORDERING PHYSICIAN: LAST NAME MANAGED CARE PHYSICIAN: FIRST NAME MANAGED CARE PHYSICIAN: LAST NAME MANAGED CARE PHYSICIAN PHONE: This patient would find it physically and / or psychologically taxing because of advanced age /or physical limitations to receive an X-RAY outside this location. This test is medically necessary for the diagnosis and treatment of this patient. Insurance Info MEDICARE: MEDICAID: STATE: CO / OTHER INSURANCE: POLICY: AGE 55 AND UNDER: I AM/AM NOT PREGNANT. IF YES, SHEILDING WAS USED WHEN POSSIBLE. PT. SIGNATURE Patient Info PATIENT’S SOCIAL SECURITY NUMBER: RESPONSIBLE PARTY NAME STREET CITY STATE ZIP PHONE: I REQUEST THAT PAYMENT OF AUTHORIZED MEDICARE AND/OR ANY INSURANCE BENEFITS BE MADE DIRECTLY TO QUALITY MEDICAL IMAGING AND/OR THE INTERPRETING PHYSICIAN FOR ANY SERVICES FURNISHED ME BY THAT PHYSICIAN OR SUPPLIER. I AUTHORIZE ANY HOLDER OF MEDICAL INFORMATION ABOUT ME TO RELEASE TO THE HEALTH CARE FINANCING ADMINISTRATION AND ITS AGENTS ANY INFORMATION NEEDED TO DETERMINE THESE BENEFITS PAYABLES FOR RELATED SERVICES. I also acknowledge that all services may not be covered in full by my insurance and I will pay in full any balance due. Desired Exams CHEST none71045 Chest (1 view)71046 Chest (2 view)71047 Chest (3 view)71048 Chest (4 view) HEAD & NECK none70250 Skull (4 view)70220 Sinuses (3 view)70110 Mandible (4 view)70150 Facial Bones (3 view)70160 Nasal Bones (3 view)70200 Orbits (4 view)70140 Maxilla (2 view)70360 Soft Tissue Neck (2) SPINE none72050 Cervical (4 view)72070 Thoracic (2 view)72100 Lumbar (3 view)72220 Sacrum/Coccyx (2)72170 Pelvis (1 view) UPPER EXTREMITY RIGHT - LEFT none73030 Shoulder (2 view)73000 Clavicle (2 view)73090 Forearm (2 view)73080 Elbow (3 view)73100 Wrist (2 view)73110 Wrist (3 view)73130 Hand (3 view)73140 fingers (2 view) LOWER EXTREMITY RIGHT - LEFT none73502 Hip Unil w/ Pelvis (2-3view)73552 Femur (2 view)73562 Knee (3 view)73590 Tibia/Fibula (2 view)73610 Ankle (3 view)73630 Foot (3 view)73650 Heel/Calcaneus (2 view) GASTRO-UROLOGICAL none74018 Abdomen/KUB (1 view)74019 Abdomen (2 view)74021 Abdomen (3 0r more view) ELECTROCARDIOGRAM none93005 EKG INTERVENTIONAL none76937 U/S Guidance ECHOCARDIOGRAM none93306 Echocardiogram ULTRASOUND none76536 Thyroid/Neck76642 Breast Ultrasound Limited76700 Abdominal76770 Retroperitoneal76805 OB U/S76856 Pelvic Ultrasound76870/93975 Scrotum/Testicle93880 Carotid Doppler93925 Arterial Doppler Bilat Low Ext93930 Arterial Doppler Bilat Upp Ext93970 Venous Doppler Bilat93971 Venous Doppler Unilat Mobile Services & Notes Please Note Reason for Mobile Services: NOTES: Symptoms / Brief History/Diagnoses: (Attach Doctor order ) CHART RADIOLOGIST R0070-Transport (1 pt) R0075-Transport (>1 pt) Q0092-setup 99058-STAT exam 01 +1 (619) 802-0204 02 911 E Valley Pkwy B, Escondido, CA 92025, USA03 info@bersamobilexray.com
