PLACE LABEL HERE

OUTPATIENT ORDERS – PRECERTIFIED EXAMS

Imaging Services- MRI

Imaging Scheduling:
Phone:678-312-3444
Fax:678-442-9736
Precertification: 678-312-4095
Location of Scheduled Appointment:
Gwinnett Medical Center – Lawrenceville
631 Professional Drive – Suite 190
Outpatient Center at GMC – Duluth
GMC Imaging Center – Hamilton Mill / GMC to Schedule Patient?  Yes  No Patient already scheduled?  Yes  No
Appointment Date: ______
ArrivalTime: ______
Exam Time: ______
GMC to Precert Patient? Yes  No
*If yes, copy of insurance card & clinical documentation must be sent with order*
Medicare? Yes  No
Precertification # : ______/ NAME:______
DOB: ______
Allergies:______
Phone: ______
PATIENT MUST BRING THIS ORDER ON THE DATE OF SERIVCE.
Send copy CD
EVALUATE CREATININE LEVEL PRIOR TO TEST UNLESS LEVEL PERFORMED WITHIN 7 DAYS. RESULT:______
Contrast per Radiologist discretion
Anxiolysis/Anesthesia - Requests for anesthesia must be scheduled through Imaging Scheduling
MRI clearance films______ / Reason for test: ______
______
Please include signs and symptoms if diagnosis is suspected or to be ruled out.
NEURO:
Brain
w/o contrast 70551
w/o & w/ contrast 70553
Orbit
w/o & w/ contrast 70543
w/o contrast 70540
Neck/Face
w/o & w/ contrast 70543
w/o contrast 70540
Pituitary
w/o & w/ contrast 70553
IAC
w/o & w/ contrast 70553
SPINE:
Cervical
w/o contrast 72141
w/o & w/ contrast 72156
Thoracic
w/o contrast 72146
w/o & w/ contrast 72157
Lumbar
w/o contrast 72148
w/o & w/ contrast 72158
Sacrum-SI Joints
w/o contrast 72195
w/o & w/ contrast 72197 / ABDOMINAL:
Abdomen
w/o contrast 74181
w/o & w/ contrast 74183
MRCP
w/o contrast 74181
Adrenals
w/o contrast 74181
w/o & w/ contrast 74183
Kidney
w/o contrast 74181
w/o & w/ contrast 74183
Liver
w/o contrast 74181
w/o & w/ contrast 74183
Pelvis (Gyn–Prostate)
w/o contrast 72195
w/o & w/ contrast 72197
CARDIAC:
w/o contrast 75557
w/o & w/ contrast 75561
with velocity flow mapping 75565 / MUSCULOSKELETAL:
 Rt  Lt  Bilateral
Shoulder
w/o contrast 73221
Arthrogram 23350/73222
Hip
w/o contrast 73721
Arthrogram 27093/73722
Elbow
w/o contrast 73221
Arthrogram 24220/73222
Knee
w/o contrast 73721
Arthrogram 27370/73722
Wrist
w/o contrast 73721
Arthrogram 25246/73222
Ankle
w/o contrast 73721
Arthrogram 27648/73722
Brachial Plexus
w/o contrast 73218
w/o & w/ contrast 73220
TUMORS/INFECTIONS
Musculoskeletal soft tissue
w/o & w/ contrast 73723 / MUSCULOSKELETAL:
Pelvis (Bony)/Hip
w/o contrast 72195
w/o & w/ contrast 72197
Foot
w/o contrast 73721
w/o & w/ contrast 73723
MRI ANGIOGRAPHY:
Circle of Willis (Intracranial)
w/o contrast 70544
Carotid Bifurcations (Neck)
w/o contrast 70547
with contrast 70548
Abdomen (Aorta, Renals, Mesenteric)
w/o & with contrast C8902
Pelvis
w/o & with contrast C8920
Run-off (Aorta and Bilateral legs)
Abdomen w/o & w conC8902
Pelvis w/o & w contrast C8920
Lower extremity. w/o & w con C8914
MR Venography – Brain
w/o contrast 70544
w/o & w contrast 70546

 STAT Results to:  Phone or  Fax: ______ Hold Patient and Call Physician’s cell #: ______

______

DateTimePhysician SignaturePhysician Name (print)PID Number

Tests should only be ordered that are medically necessary for the diagnosis, symptoms, and/or treatement. The patient may be billed for tests that are not deemed necessary by payors. Please submit all (appropriate) clinical indications for all test(s) ordered. The procedure will not be performed in the absence of the completed form including the appropriate diagnosis supporting the ordered procedure. Ordering physicians are responsible for the accuracy of the information provided.

*1-39811* FORM 1-39811 REV. 08/2018 Page 1 of 1

OUTPATIENT ORDERS – PRECERTIFIED EXAMS

Imaging Services – MRI

Reference Page

FORM 1-39811 REV. 08/2018 Not Part of Medical Record Reference Page Only