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PATIENT’S LEGAL NAME DATE OF BIRTH PATIENT SIGNS/SYMPTOMS SPECIAL INSTRUCTIONS PHYSICIAN NAME (please print) Revised: 06/2017 ORDERING PHYSICIAN’S SIGNATURE DATE/TIME ❑ CALL REPORT TO_____________________________________ ❑ FAX REPORT TO______________________________________ PATIENT PHONE INSURANCE COMPANY NAME PHYSICIAN OFFICES Tests cannot be performed without listing the signs/symptoms and/or reason(s) for each test ordered along with the ICD-10 code. Federal law requires that we inform you when ordering tests that will be paid under federal health programs, including Medicare and Medicaid, physicians should only order tests that are medically necessary for diagnosis or treatment of the patient, not for screening purposes. Signature Stamps Are Not Valid X OUTPATIENT ORDER FORM RADIOLOGY Appt. Date: _____________________ Appt. Time: _____________________ Arrival Time: _____________________ MAIN HOSPITAL 1230 Baxter St., Athens, GA OUTPATIENT DIAGNOSTIC CENTER 2470 Daniells Bridge Rd., Athens, GA TO SCHEDULE: 706.389.2700 FAX this order and required clinical records to: 706.389.2001 DIAGNOSTIC unscheduled cranial ___ facial bones 70150 ___ mandible 70110 ___ nasal bones 70160 ___ sinuses 70220 ___ skull 70260 ___ waters view 70210 thorax ___ chest 2-view 71020 ___ ribs bilateral 71111 spine ___ c-spine 1-view 72020 ___ c-spine 2-view 72040 ___ c-spine flex/ext only 72040 ___ c-spine complete w/f/e 72052 ___ c-spine complete 72052 ___ t-spine 3-view 72072 ___ l-spine 2-view 72100 ___ l-spine flex/ext 72100 ___ l-spine complete w/f/e 72114 ___ l-spine complete 72110 ___ scoliosis survey 72069 abdomen ___ abdomen/kub 74000 ___ abdomen 2-view 74010 ___ abdomen series 74022 ___ sitz marker 74000 upper extremeties ___ elbow (r/l) 73080 ___ finger(s) (r/l) 73140 ___ forearm (r/l) 73090 ___ hand (r/l) 73130 ___ humerus (r/l) 73060 ___ shoulder (r/l) 73030 ___ wrist 2-view (r/l) 73100 ___ wrist complete (r/l) 73110 lower extremeties ___ ankle 2-view (r/l) 73600 ___ ankle complete (r/l) 73610 ___ femur (r/l) 73550 ___ foot (r/l) 73630 ___ hips, bilateral 73520 ___ hip (r/l) 73510 ___ knee 2-view (r/l) 73560 ___ knee complete (r/l) 73564 ___ os calcis (heel) (r/l) 73650 ___ pelvis, ap 72170 ___ tibia/fibula (r/l) 73590 ___ toe(s) (r/l) 73660 other ___ other_____________ DIAGNOSTIC scheduled ___ arthrogram________________ ___ barium enema (adult/peds) 74270 ___ barium enema w/air 74280 ___ barium swallow (esophagram) 74220 ___ cervical myelogram 72240 ___ enteroclysis 74251 ___ hsg 74740 ___ lumbar myelogram 72265 ___ modified barium swallow 74230 ___ sialogram 70390 ___ small bowel (adult/peds) 74250 ___ thoracic myelogram 72255 ___ ugi series 74246 ___ ugi w/small bowel 74249 ___ vcug 74455 ct ___ abdomen w/contrast 74160 ___ abdomen w & w/o contrast 74170 ___ abdomen w/o contrast 74150 ___ biopsy: _____________ 77012 ___ calcium scoring (hospital only) 75571 ___ c-spine w/o contrast 72125 ___ chest w/contrast 71260 ___ chest w/o contrast 71250 ___ chest super d w/contrast 71260 ___ chest super d w/o contrast 71250 ___ enterography 74160 ___ head w & w/o contrast 70470 ___ head w/o contrast 70450 ___ l-spine w/o contrast 72131 ___ lower extremity w/o contrast 73700 ___ mastoid (iacs) w/contrast 70481 ___ max facial w/contrast 70487 ___ neck (soft tissue) w/contrast 70491 ___ orbits w/contrast 70481 ___ pelvis w/contrast 72193 ___ pelvis w/o contrast 72192 ___ sinuses complete w/o contrast 70486 ___ t-spine w/o contrast 72128 ___ upper extremity w/o contrast 73200 ct angio ___ ct angio abdomen 74175 ___ ct angio abdomen w/runoff 75635 ___ ct angio chest 71275 ___ ct angio coronary 75574 ___ ct angio head 70496 ___ ct angio neck 70498 ___ ct angio pelvis 72191 ___ other:____________________ mri no patients with pacemakers ___ abdomen w & w/o contrast 74183 ___ abdomen w/o contrast 74181 ___ ankle w & w/o contrast (r/l) 73723 ___ ankle w/o contrast (r/l) 73721 ___ brain w & w/o contrast 70553 ___ brain w/o contrast 70551 ___ breast bilateral w & w/o contrast 77059 ___ c-spine w & w/o contrast 72159 ___ c-spine w/o contrast 72141 ___ chest w & w/o contrast 71552 ___ chest w/o contrast 71550 ___ hip w & w/o contrast (r/l) 73723 ___ hip w/o contrast (r/l) 73721 ___ iac w & w/o contrast 70553 ___ l-spine w & w/o contrast 72158 ___ l-spine w/o contrast 72148 ___ orbits w & w/o contrast 70543 ___ pelvis w & w/o contrast 72197 ___ pelvis w/o contrast 72195 ___ pituitary w & w/o contrast 70553 ___ sacrum w & w/o contrast 72197 ___ sacrum w/o contrast 72195 ___ t-spine w & w/o contrast 72157 ___ t-spine w/o contrast 72146 ___ tmj 70336 ___ other: _________________ mr angio ___ mra abdomen w/contrast ___ mra abdomen w & w/o contrast C8902 ___ mra head w/o contrast 70544 ___ mra lower extremity w & w/o contrast C8914 ___ mra neck w/o contrast 70547 ___ mra neck w & w/o contrast 70549 ___ mra renal artery w & w/o contrast C8902 ___ lower extremity: specify _________________ ___ upper extremity: specify _________________ nuclear medicine ___ bone scan total body 78306 nuclear medicine continued ___ bone scan 3-phase 78315 ___ gallium scan 78802 ___ gastric emptying 78264 ___ gi bleed scan 78278 ___ hida scan 78223 ___ hida scan w/cck 78223 ___ i-123 thyroid (uptake/scan) 78006 ___ i-131 therapy 79005 ___ i-131 whole body scan 78018 ___ wbc localization 78806 ___ liver spect 78205 ___ liver/spleen scan 78215 ___ vq lung scan 78588 ___ lung scan w/quant diff 78596 ___ lymphoscintigraphy 78195 ___ meckels scan 78290 ___ muga 78472 ___ myocardial perfusion multi 78452 ___ octreotide scan 78802 ___ parathyroid 78070 ___ renal scan 78707 ___ renal scan w/captopril 78709 ___ renal scan w/lasix 78708 ___ technesium thyroid 78010 ___ other: _________________ ultrasound ___ abdomen 76700 ___ aorta 76770 ___ biophysical profile 76818 ___ breast: ___ r ___l ___b 76645 ___ cranial 76506 ___ extremity nonvascular (r/l) 76880 ___ gallbladder/pancreas 76705 ___ kidneys/renal 76770 ___ liver 76705 ___ ob cpt ______________ ___ paracentesis 49080 ___ pelvis – non ob 76856 ___ spine 76800 ___ testicular/scrotum 76870 ___ thoracentesis 32421 ___ thyroid 76536 ___ biopsy/other: specify _______________ Your office will be contacted prior to test being performed if form is not complete. ICD-10 CODE:

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Page 1: Appt. Date: OUTPATIENT ORDER FORM RADIO LOGY Appt. …...___ barium enema w/air 74280 ___ barium swallow (esophagram) 74220 ___ cervical myelogram 72240 ___ enteroclysis 74251 ___

PATIENT’S LEGAL NAME DATE OF BIRTH

PATIENT SIGNS/SYMPTOMS

SPECIAL INSTRUCTIONS

PHYSICIAN NAME (please print)

Revised: 06/2017

ORDERING PHYSICIAN’S SIGNATURE DATE/TIME

❑ CALL REPORT TO_____________________________________

❑ FAX REPORT TO______________________________________

PATIENT PHONE INSURANCE COMPANY NAME

PHYSICIAN OFFICES Tests cannot be performed without listing the signs/symptoms and/or reason(s) for each test ordered along with the ICD-10 code. Federal law requires that we inform you when ordering tests that will be paid under federal health programs, including Medicare and Medicaid, physicians should only order tests that are medically necessary for diagnosis or treatment of the patient, not for screening purposes.

Signature Stamps Are Not Valid

X

OUTPATIENT ORDER FORMRADIOLOGY

Appt. Date: _____________________

Appt. Time: _____________________

Arrival Time: _____________________

MAIN HOSPITAL1230 Baxter St., Athens, GA

OUTPATIENT DIAGNOSTIC CENTER2470 Daniells Bridge Rd., Athens, GA

TO SCHEDULE: 706.389.2700FAX this order and required clinical records to: 706.389.2001

DIAGNOSTIC unscheduledcranial___ facial bones 70150___ mandible 70110___ nasal bones 70160___ sinuses 70220___ skull 70260___ waters view 70210thorax___ chest 2-view 71020___ ribs bilateral 71111spine___ c-spine 1-view 72020 ___ c-spine 2-view 72040___ c-spine flex/ext only 72040___ c-spine complete w/f/e 72052___ c-spine complete 72052___ t-spine 3-view 72072___ l-spine 2-view 72100___ l-spine flex/ext 72100 ___ l-spine complete w/f/e 72114___ l-spine complete 72110___ scoliosis survey 72069abdomen___ abdomen/kub 74000___ abdomen 2-view 74010___ abdomen series 74022___ sitz marker 74000 upper extremeties___ elbow (r/l) 73080___ finger(s) (r/l) 73140___ forearm (r/l) 73090___ hand (r/l) 73130___ humerus (r/l) 73060___ shoulder (r/l) 73030___ wrist 2-view (r/l) 73100___ wrist complete (r/l) 73110lower extremeties___ ankle 2-view (r/l) 73600___ ankle complete (r/l) 73610___ femur (r/l) 73550___ foot (r/l) 73630___ hips, bilateral 73520___ hip (r/l) 73510___ knee 2-view (r/l) 73560___ knee complete (r/l) 73564___ os calcis (heel) (r/l) 73650___ pelvis, ap 72170___ tibia/fibula (r/l) 73590___ toe(s) (r/l) 73660other___ other_____________

DIAGNOSTIC scheduled___ arthrogram___________________ barium enema (adult/peds) 74270___ barium enema w/air 74280___ barium swallow (esophagram) 74220___ cervical myelogram 72240___ enteroclysis 74251 ___ hsg 74740___ lumbar myelogram 72265___ modified barium swallow 74230___ sialogram 70390___ small bowel (adult/peds) 74250___ thoracic myelogram 72255___ ugi series 74246___ ugi w/small bowel 74249___ vcug 74455ct___ abdomen w/contrast 74160___ abdomen w & w/o contrast 74170___ abdomen w/o contrast 74150___ biopsy: _____________ 77012___ calcium scoring (hospital only) 75571___ c-spine w/o contrast 72125___ chest w/contrast 71260___ chest w/o contrast 71250___ chest super d w/contrast 71260___ chest super d w/o contrast 71250___ enterography 74160___ head w & w/o contrast 70470___ head w/o contrast 70450___ l-spine w/o contrast 72131___ lower extremity w/o contrast 73700___ mastoid (iacs) w/contrast 70481___ max facial w/contrast 70487___ neck (soft tissue) w/contrast 70491___ orbits w/contrast 70481___ pelvis w/contrast 72193___ pelvis w/o contrast 72192___ sinuses complete w/o contrast 70486___ t-spine w/o contrast 72128 ___ upper extremity w/o contrast 73200ct angio ___ ct angio abdomen 74175___ ct angio abdomen w/runoff 75635___ ct angio chest 71275 ___ ct angio coronary 75574 ___ ct angio head 70496___ ct angio neck 70498___ ct angio pelvis 72191___ other:____________________

mri no patients with pacemakers

___ abdomen w & w/o contrast 74183___ abdomen w/o contrast 74181___ ankle w & w/o contrast (r/l) 73723___ ankle w/o contrast (r/l) 73721___ brain w & w/o contrast 70553___ brain w/o contrast 70551___ breast bilateral w & w/o contrast 77059___ c-spine w & w/o contrast 72159___ c-spine w/o contrast 72141___ chest w & w/o contrast 71552___ chest w/o contrast 71550___ hip w & w/o contrast (r/l) 73723___ hip w/o contrast (r/l) 73721___ iac w & w/o contrast 70553___ l-spine w & w/o contrast 72158___ l-spine w/o contrast 72148___ orbits w & w/o contrast 70543___ pelvis w & w/o contrast 72197___ pelvis w/o contrast 72195___ pituitary w & w/o contrast 70553___ sacrum w & w/o contrast 72197___ sacrum w/o contrast 72195___ t-spine w & w/o contrast 72157___ t-spine w/o contrast 72146___ tmj 70336___ other: _________________mr angio___ mra abdomen w/contrast___ mra abdomen w & w/o contrast C8902___ mra head w/o contrast 70544___ mra lower extremity w & w/o contrast C8914___ mra neck w/o contrast 70547___ mra neck w & w/o contrast 70549___ mra renal artery w & w/o contrast C8902___ lower extremity: specify ____________________ upper extremity: specify _________________nuclear medicine___ bone scan total body 78306

nuclear medicine continued___ bone scan 3-phase 78315___ gallium scan 78802___ gastric emptying 78264___ gi bleed scan 78278___ hida scan 78223___ hida scan w/cck 78223___ i-123 thyroid (uptake/scan) 78006___ i-131 therapy 79005___ i-131 whole body scan 78018___ wbc localization 78806___ liver spect 78205___ liver/spleen scan 78215___ vq lung scan 78588___ lung scan w/quant diff 78596___ lymphoscintigraphy 78195___ meckels scan 78290___ muga 78472___ myocardial perfusion multi 78452___ octreotide scan 78802___ parathyroid 78070___ renal scan 78707___ renal scan w/captopril 78709___ renal scan w/lasix 78708___ technesium thyroid 78010___ other: _________________ultrasound___ abdomen 76700 ___ aorta 76770___ biophysical profile 76818___ breast: ___ r ___l ___b 76645___ cranial 76506 ___ extremity nonvascular (r/l) 76880 ___ gallbladder/pancreas 76705___ kidneys/renal 76770 ___ liver 76705___ ob cpt ______________ ___ paracentesis 49080___ pelvis – non ob 76856___ spine 76800 ___ testicular/scrotum 76870 ___ thoracentesis 32421___ thyroid 76536___ biopsy/other: specify _______________

Your office will be contacted prior to test being performed if form is not complete.

ICD-10 CODE:

Page 2: Appt. Date: OUTPATIENT ORDER FORM RADIO LOGY Appt. …...___ barium enema w/air 74280 ___ barium swallow (esophagram) 74220 ___ cervical myelogram 72240 ___ enteroclysis 74251 ___

Home Health Careand Hospice Offices1021 Jamestown Blvd

Athens Perimeter

Lu

mpkin S

t

Oglethorpe Ave

Dan

ielsv

ille

Rd

Comm

erce Hwy

Lexington Rd

East Campus D

r

Jefferson Rd

Tallassee Rd

Atlanta Hwy

Mac

on H

wy

Hospice House1660 Jennings Mill Rd

Highland Hills1660 Jennings Mill Rd

Center for Alzheimer’s and Dementia Care1660 Jennings Mill Rd

DowntownAthens

College Ave Oconee St

Oak StThomas St

(Athens Perimeter ends on Old Hull Rd)

Westlake Dr

Alps RdHaw

thorne Ave

Broad St

Baxter St

Milledge Ave

(map is not to scale)

for information call: 706-389-3000 or 1-800-233-STMH

North

Ave

Epps

Brid

ge P

kwy

Athens/Ben EppsAirport

Prince Ave

8 2978

78

129

441

106

29

72

441129

10LP

10LP

78

316

Jamestown

Blvd

Mag

nolia

Str

eet

Outpatient Diagnostic, Rehab andWellness Center at The Exchange2470 Daniells Bridge Rd, Bldg 300

Daniells Bridge Rd

Oconee Connector

patient & visitorparkingdeckIncludes handicap parking

Children’sSpecialtyServices

Baxter Street

Alp

s R

oad

ST. MARY’S HOSPITAL

staff parking

Patient Drop-off& Pick-up

Main EntranceRegistration

OutpatientSurgical

Center

staff parking

Emergency Center Entrance

To Magnolia St/Broad St

To Broad St

Cross walk

College Station Rd

TheUniversity of Georgia

Je

nnin

gs M

ill

Rd

Hog Mountain Rd

Hog Mtn Rd

MLK Pkwy

Mars Hill Rd

Athens Perimeter

www.stmarysathens.org

Mars Hill Rd

Center for Wound Healing4017 Atlanta Hwy, Suite A

ST. MARY’S HOSPITAL1230 Baxter St


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