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Check in Time
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Order date
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Appointment date
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Appointment Time
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Insurance authorization #
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Scheduled by
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Taken by:
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Primary phone
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Secondary phone
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Previous related studies: Where performed?
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If Other, Specify
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Ordering / Referring Provider name
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CC Provider(s)
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Fax
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Report
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Exam Requested
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X-Ray (Non-Scheduled Studies)
• • •
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If Other, Specify
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X-Ray (Scheduled Studies)
• • •
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If Other, Specify
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Arthogram
• • •
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Myelogram w/CT
• • •
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Bone Density Study (DEXA)
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CT - Computed Tomography
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CT Chest / ABO / Pelvis
• • •
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CT Head / Neck
• • •
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If Limited and/or Other, Specify
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CT Spine (w/o contrast)
• • •
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CT Extremities
• • •
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If Extremity, Specify
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CT Angio (All with & w/o IV contrast / no oral contrast)
• • •
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Perform Exam
• • •
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New Free Draw
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Mammography
• • •
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Ultrasound
• • •
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Duplex Scans
• • •
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If Other, Specify / Specify Joint / Specify weeks
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Please Specify Narrative Diagnosis: (Do not use RuleOut, Probable, Possible,Suspected,or Routine- these are not diagnoses.)
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