For your convenience, we offer secure on-line scheduling for imaging appointments. We will print a copy of this form and retain it in our records. In this way, your on-line request qualifies as a proper written provider's order according to CMS regulations. This on-line communication is securely encrypted and meets HIPAA and Medicare requirements.

Please telephone for urgent or same-day appointments: (518) 438-0600.

Carefully complete all information requested, paying particular attention to the Clinical Diagnosis or Signs and Symptoms. We rely on the information that you provide us to establish the medical necessity of the examination(s) that you have requested.

Once you have submitted this information, a printer-friendly copy of your request will be generated instantly. You may want to print a copy for your records.

Referring Provider Information:

Name:

Send Additional Reports To:

Scheduled By:

Provider's Email Address For Questions:

Provider's Office Telephone: Schedulers' Ext.: (Necessary only if you are a new referrer to our office.)

Patient Information:

Name (Last, First and Middle Initial): ,

Date of Birth (mm/dd/yyyy):

Patient's Telephone: Home Work
(Please do not list any telephone number at which the patient is unwilling to be contacted.)

Primary Health Insurance Company:
choose one Blue Shield NE NY CDPHP Empire Blue Cross GHI PPO Medicare MVP No Fault NYS Empire Plan United Healthcare Workers Comp. Other (please specify) or Other:

Secondary Health Insurance Company:
choose one Blue Shield NE NY CDPHP Empire Blue Cross GHI PPO Medicare MVP No Fault NYS Empire Plan United Healthcare Workers Comp. Other (please specify) or Other:

Health Insurance Subscriber Name (Last, First and Middle Initial):
,

Patient is the Health Insurance Subscriber

Exam #1 Type: choose one CT Scan CT Sagittal/Coronal/3-D Reconstructions CT Angiography (CTA) DEXA MRI Scan MR Angiography (MRA) Nuclear Medicine Ultrasound X-Ray

Body Part:

Left
Right
Bilateral

Contrast: choose one With Contrast DO NOT GIVE CONTRAST

Authorization or Pre-Certification Number:

Authorization Not Required

Clinical Diagnosis or Signs and Symptoms:

Exam #2 Type: choose one CT Scan CT Sagittal/Coronal/3-D Reconstructions CT Angiography (CTA) DEXA MRI Scan MR Angiography (MRA) Nuclear Medicine Ultrasound X-Ray

Body Part:

Left
Right
Bilateral

Contrast: choose one With Contrast DO NOT GIVE CONTRAST

Authorization or Pre-Certification Number:

Authorization Not Required

Clinical Diagnosis or Signs and Symptoms:

Exam #3 Type: choose one CT Scan CT Sagittal/Coronal/3-D Reconstructions CT Angiography (CTA) DEXA MRI Scan MR Angiography (MRA) Nuclear Medicine Ultrasound X-Ray

Body Part:

Left
Right
Bilateral

Contrast: choose one With Contrast DO NOT GIVE CONTRAST

Authorization or Pre-Certification Number:

Authorization Not Required

Clinical Diagnosis or Signs and Symptoms:

Please order any additional exams under "Remarks" below.

Remarks:

For Reference:

Click here for Medicare Local Medical Review Policies

By submitting this form, I certify that I am a licensed provider or his/her designee. This form should not be used by anyone not authorized to order medical imaging examinations.