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Get Blank Mri Outpatient Form

Place Label HERE Imaging Services Contingency Order Info for MT Downtime MRI Order Room One Nolte Drive Kittanning PA 16201 RAD-2963-FFE Orig 2/93 Rev 7/09 6/12 MR Acct Fax 724-543-8855 Physician Signature Physician PRINTED Name Patient Name DOB SSN XXX-XX- Address Phone Number Gender M / F Please follow the preparation listed below and bring this form and any referrals needed to the Outpatient Registration desk hour before your appointment. If you have been pre-registered by phone please arrive 15 minutes before. Primary Insurance DIAGNOSIS Include ICD9 Policy Number Required Auth Number Required based on Insurance Policy Physician note pertaining to exam MRI Appointment Do Orbit X-Ray for patient with potential of Metallic foreign body prior to MRI-PRN Date Brain Soft Tissue Neck TMJ Brachial Plexus Breast Abdomen check one Liver Adrenals Kidneys Pancreas MRCP Abdomen prep MRI 1 Cervical Spine Thoracic/dorsal Spine Lumbar Spine w/ Reconstructions Pelvis Circle one SI Joint Rt Lt Shoulder Elbow Wrist Hand Hip Knee Leg Foot Ankle MRA Aorta MRA Head Intracranial Vessels MRA Carotids Extracranial Vessels MRA Renal Arteries MRA Aorta with Bil Extremity Run-Off Other Time AM / PM Location ACMH Hospital Imaging Center Patient Prep List For Scheduling changes please call 724-543-8131 To Pre-Register for your appointment please call 724-543-8832 A signed physician order is required at the time of your appointment. Place Label HERE Imaging Services Contingency Order Info for MT Downtime MRI Order Room One Nolte Drive Kittanning PA 16201 RAD-2963-FFE Orig 2/93 Rev 7/09 6/12 MR Acct Fax 724-543-8855 Physician Signature Physician PRINTED Name Patient Name DOB SSN XXX-XX- Address Phone Number Gender M / F Please follow the preparation listed below and bring this form and any referrals needed to the Outpatient Registration desk hour before your appointment. If you have been pre-registered by phone please arrive 15 minutes before. Primary Insurance DIAGNOSIS Include ICD9 Policy Number Required Auth Number Required based on Insurance Policy Physician note pertaining to exam MRI Appointment Do Orbit X-Ray for patient with potential of Metallic foreign body prior to MRI-PRN Date Brain Soft Tissue Neck TMJ Brachial Plexus Breast Abdomen check one Liver Adrenals Kidneys Pancreas MRCP Abdomen prep MRI 1 Cervical Spine Thoracic/dorsal Spine Lumbar Spine w/ Reconstructions Pelvis Circle one SI Joint Rt Lt Shoulder Elbow Wrist Hand Hip Knee Leg Foot Ankle MRA Aorta MRA Head Intracranial Vessels MRA Carotids Extracranial Vessels MRA Renal Arteries MRA Aorta with Bil Extremity Run-Off Other Time AM / PM Location ACMH Hospital Imaging Center Patient Prep List For Scheduling changes please call 724-543-8131 To Pre-Register for your appointment please call 724-543-8832 A signed physician order is required at the time of your appointment.

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