Podiatric Radiology Referral - RadNet - Leading Radiology Forward · 2020-03-27 · Thank you for...
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Foot w/o contrast (CPT 73718) Foot w/contrast (CPT 73719) Foot w/wo (CPT 73720) Other ____________________ _______________________ Ankle w/o contrast (CPT 73721) Ankle w/contrast (CPT 73722) Ankle w/wo (CPT 73723) Other ____________________ w/o contrast (CPT 73700) w/contrast (CPT 73701) w/wo (CPT 73702) Other ____________________ STAT CALL REPORT FAX REPORT FILMS W/PATIENT FILMS W/REPORT IMAGES ON CD ULTRASOUND NUCLEAR MEDICINE HISTORY OF PRESENTING PROBLEM & SPECIAL INSTRUCTIONS Referring Provider Signature: _____________________________________________________ Date Signed: RADNET_OC_PODIATRIC_RADIOLOGY_REV01132020VER1MC __________________ Tib / Fib Left Right Foot / Ankle Whole Body Limited Three Phase Whole Body Limited Three Phase Left Right Other _________________ To Schedule: PLEASE COMPLETE IN FULL and Call or Fax Today’s Date: _______________ Time Referral Submitted:______________ PATIENT’S NAME: _____________________________________ DOB: _____________________________________________ Phone: ____________________________________________ Cell: ______________________________________________ Referring Physician: _____________________________________ Phone: _____________________________________________ Physician Address: ______________________________________ __________________________________________________ Duplicate Report To: _____________________________________ Forefoot (Includes: Mid-foot) Diagnosis (Chose One): Foot Trauma Lisfranc Fx Morton’s Neuroma Osteomyelitis Stress Fx Turf Toe Other Dx:_________________ _______________________ Ankle (Includes: Hind Foot to Ankle) Diagnosis (Chose One): Achilles Tendon Ankle Trauma Osteomyelitis Peroneal Tendon Dysfunction Plantar Fascia Tibial Tendon Dysfunction Other Dx:__________________ _________________________ Forefoot (includes Mid-foot) Ankle (includes Hind foot to Ankle) Left Right Left Right CT MRI Foot Left Right Mid-Foot / Hind Foot / Ankle Left Right Other_____________________ ________________________________ Tib / Fib Foot / Ankle Left Right Left Right Thank You for choosing a RadNet Center Scheduling Hours: Monday - Friday: 8am - 6pm For Directions and site information see back of this form* (76881) (76881) REMINDER: X-RAYS ARE TAKEN ON A WALK-IN BASIS AND NO APPOINTMENT IS REQUIRED. Go to radnet.com/orange-county for more details. CT Contrast Studies Only. Labs must be completed within the past 90 days. Labs needed if: __Hypertension __Age >80 __ Diabetes __ Renal Disease If Labs have been completed within the past 90 days please provide values and fax lab results: Creatinine / GFR _________ /_________ Podiatric Radiology Referral Tax ID#: 954651287 - CHECK REQUESTED SITE - For all scheduling needs: Fax order or Phone to schedule 784-1643 (P) 285-9084 (F) (714) 387-5000 (P) 753-9030 (F) (949) 299-6230 (P) 627-0923 (F) (562) MemorialCare - Irvine West Coast Radiology Irvine X-Ray West Coast Radiology Irvine MemorialCare - San Clemente Saddleback Valley Radiology West Coast Radiology Mission Viejo Wave - Laguna Woods Downey Advanced Imaging Garden Grove Advanced Imaging Liberty Pacific Advanced Imaging Long Beach Anaheim Advanced Imaging Anaheim Advanced Imaging - X-Ray Lakewood Open MRI Los Coyotes Imaging Center MemorialCare - Long Beach Orange Adv./ Orange Imaging Center MemorialCare - Fountain Valley Invision - Newport Beach MemorialCare - Huntington Beach MemorialCare - Newport Beach Wave Interventional Radiology & Imaging Center West Coast Radiology Santa Ana Foot Left Right (73630) (73610) (73660) Mid-Foot/Hind Foot/Ankle Left Right Sesamoids Other_____________________________ EXTREMITY X-RAY Weight Bearing Non-Weight Bearing
Transcript of Podiatric Radiology Referral - RadNet - Leading Radiology Forward · 2020-03-27 · Thank you for...
Foot w/o contrast (CPT 73718) Foot w/contrast (CPT 73719) Foot w/wo (CPT 73720) Other ____________________
_______________________
Ankle w/o contrast (CPT 73721) Ankle w/contrast (CPT 73722) Ankle w/wo (CPT 73723) Other ____________________
_______________________
w/o contrast (CPT 73700) w/contrast (CPT 73701) w/wo (CPT 73702) Other ____________________
STAT CALL REPORT FAX REPORT FILMS W/PATIENT FILMS W/REPORT IMAGES ON CD
ULTRASOUNDNUCLEAR MEDICINE
HISTORY OF PRESENTING PROBLEM & SPECIAL INSTRUCTIONS
Referring Provider Signature: _____________________________________________________ Date Signed:
RADNET_OC_PODIATRIC_RADIOLOGY_REV01132020VER1MC
__________________
Tib / Fib Left Right
Foot / Ankle Whole Body Limited Three Phase
Whole Body Limited Three Phase Left Right
Other _________________
To Schedule: PLEASE COMPLETE IN FULL and Call or Fax Today’s Date: _______________ Time Referral Submitted:______________
PATIENT’S NAME: _____________________________________
DOB: _____________________________________________
Phone: ____________________________________________
Cell: ______________________________________________
Referring Physician: _____________________________________
Phone: _____________________________________________
Physician Address: ______________________________________
__________________________________________________
Duplicate Report To: _____________________________________
Forefoot (Includes: Mid-foot) Diagnosis (Chose One):
Foot Trauma Lisfranc Fx Morton’s Neuroma Osteomyelitis Stress Fx Turf Toe Other Dx:_________________
_______________________
Ankle (Includes: Hind Foot to Ankle)Diagnosis (Chose One):
Achilles Tendon Ankle Trauma Osteomyelitis Peroneal Tendon Dysfunction Plantar Fascia Tibial Tendon Dysfunction Other Dx:__________________
_________________________
Forefoot (includes Mid-foot) Ankle (includes Hind foot to Ankle)
Left Right Left Right
CT MRI
Foot Left Right Mid-Foot / Hind Foot / Ankle
Left Right Other_____________________
________________________________
Tib / Fib Foot / Ankle
Left Right Left Right
Thank You for choosing a RadNet CenterScheduling Hours: Monday - Friday: 8am - 6pm For Directions and site information see back of this form*
(76881) (76881)
REMINDER: X-RAYS ARE TAKEN ON A WALK-IN BASIS AND NO APPOINTMENT IS REQUIRED. Go to radnet.com/orange-county for more details. CT Contrast Studies Only. Labs must be completed within the past 90 days. Labs needed if: __Hypertension __Age >80 __ Diabetes __ Renal DiseaseIf Labs have been completed within the past 90 days please provide values and fax lab results: Creatinine / GFR _________ /_________
Podiatric Radiology Referral
Tax ID#: 954651287
- CHECK REQUESTED SITE -
For all scheduling
needs: Fax order or Phone
to schedule
784-1643 (P)285-9084 (F)(714)
387-5000 (P)753-9030 (F)(949)
299-6230 (P)627-0923 (F)(562)
MemorialCare - Irvine
West Coast Radiology Irvine X-RayWest Coast Radiology Irvine
MemorialCare - San Clemente
Saddleback Valley RadiologyWest Coast Radiology Mission Viejo
Wave - Laguna WoodsDowney Advanced Imaging
Garden Grove Advanced Imaging
Liberty Pacific Advanced Imaging Long Beach
Anaheim Advanced ImagingAnaheim Advanced Imaging - X-Ray
Lakewood Open MRILos Coyotes Imaging Center
MemorialCare - Long Beach
Orange Adv./ Orange Imaging Center
MemorialCare - Fountain Valley
Invision - Newport Beach
MemorialCare - Huntington BeachMemorialCare - Newport Beach
Wave Interventional Radiology & Imaging Center
West Coast Radiology Santa Ana
Foot Left Right (73630) (73610)
(73660) Mid-Foot/Hind Foot/Ankle Left Right Sesamoids Other_____________________________
EXTREMITY X-RAY Weight Bearing Non-Weight Bearing
Thank you for choosing our Imaging Centers.RADNET_OC_PODIATRIC_RADIOLOGY_REV03252020VER1MC
Locations, Maps & General Information
GENERAL INFORMATION:
1. IT IS REQUIRED THAT WE HAVE A DOCTOR’S ORDER TO PERFORM
YOUR EXAM.
2. Please bring a valid ID card with you along with your insurance
card.
3. Some exams require authorization.
4. Please plan on completing registration forms prior to your exam.
5. If possible, dress in loose, comfortable, two-piece clothing.
For MRI exams, no belts, or zippers and leave your valuables
at home.
any prior exam reports/images needed for comparison.
7. Study times may vary.
Leading Radiology Forward.TM
Please go to our website RadNet.com/Orange-County for exam preparation instructions
or scan this QR code.
= X-Ray with Fluroscopy= Open System = 3T MRI = 1.5T MRI X
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For Driving Directions, call or visit our website: RadNet.com/Orange-County
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LagunaBeach
Irvine
Fullerton
NewportBeach
HuntingtonBeach
LongBeach
BuenaPark
Lakewood
Los Angeles
DanaPoint
GardenGroveSeal
Beach
Compton
SantaMonica
Downey
YorbaLinda
SantaAna
Torrance
ManhattanBeach
LagunaHills
MissionViejo
Brea
LagunaBeach
Irvine
Fullerton
NewportBeach
HuntingtonBeach
LongBeach
BuenaPark
Lakewood
Los Angeles
DanaPoint
GardenGroveSeal
Beach
Compton
SantaMonica
Downey
YorbaLinda
SantaAna
Torrance
ManhattanBeach
LagunaHills
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Downey Advanced Imaging 11525 Brookshire Ave., #111, Downey CA 90241 562-904-1111
Garden Grove Advanced Imaging 9191 Westminster Ave, #105, Garden Grove CA 92844 714-583-6314
MemorialCare - Fountain Valley 18785 Brokhurst St., #102, Fountain Valley, CA 92708 714-471-9550
Liberty Pacific Advanced Imaging Long Beach 2708 E Willow St., Signal Hill, CA 90755 562-216-5120
Anaheim Advanced Imaging
Anaheim Advanced Imaging - X-Ray
947 S Anaheim Blvd, #130, Anaheim CA 92805
710 N Euclid St, #102, Anaheim CA 92801
714-758-9800
714-517-2099
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Invision - Newport Beach 280 Newport Center Dr., #100, Newport Beach, CA 92660 949-706-2000
Lakewood Open MRI 3715 E South St., Long Beach, CA 90805 562-602-0700 O
Los Coyotes Imaging Center 3320 Los Coyotes Diagonal, #120, #112, Long Beach, CA 90808 562-216-5120 X
MemorialCare - Huntington Beach 17762 Beach Blvd., #110, Huntington Beach, CA 92647 714-898-2991 3T
MemorialCare - Irvine 4050 Barranca Pkwy., #160, Irvine, CA 92604 949-726-9500 3T
MemorialCare - Long Beach 3828 Schaufele Ave., #250, Long Beach, CA 90808 562-498-6322 3T
MemorialCare - Newport Beach 3300 West Coast Highway, #B, Newport Beach, CA 92663 714-571-2099
3T
Wave Interventional Radiology & Imaging Center 999 N. Tustin Avenue, #5, Santa Ana, CA 92705 657-232-1572
3T
MemorialCare - San Clemente 675 Camino De Los Mares, #101, San Clemente, CA 92673 949-493-8799
Saddleback Valley Radiology 23961 Calle De La Magdalena, #243, Laguna Hills, CA 92653 949-855-4301
West Coast Radiology Irvine X-Ray 14150 Culver Dr #101, Irvine, CA 92604 949-272-2083
West Coast Radiology Irvine 16300 Sand Canyon Ave, #102, Irvine CA 92618 949-753-0362
West Coast Radiology Mission Viejo 27882 Forbes Rd, #120, Laguna Niguel CA 92677 949-272-2200
Wave - Laguna Woods 24301 Paseo De Valencia, #100, Laguna Woods, CA 93637 949-462-3999
Orange Adv./ Orange Imaging Center 230 S Main St, #101, #205, Orange CA 92868 714-288-5400 X
West Coast Radiology Santa Ana 1100-A N Tustin Ave, Santa Ana CA 92705 714-835-6055 X1.5
1.5
3T
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