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Name of Patient D.O.B Home Phone Number Work Phone Number Diagnosis/Signs & Symptoms (Do Not Use “Rule Out”) Insurance Name Primary Physician (Please PRINT) Address Prior authorization number(s) Fax report delivery Call immediate verbal results/fax report to follow RAPA accepts most major insurance plans, including Blue Cross Blue Shield products, Aetna, Cigna United Health Care and QualChoice QCA. Prior authorization may be required for HITECH or Interventional Imaging. If you cannot meet your appointment, please call 501-686-2621 24-hours in advance. Chest Spine Orthopaedic RT LT Abdomen/KUB Cervical Thoracic Sinuses Bilateral Acute Abd Abdomen Flat & Upright Lumbar Abdomen (prep required) Kidneys (prep required) Gall Bladder (prep required) Aorta (prep required) Pelvis with endovaginal if necessary (prep required) Pregnancy (less than 14 weeks) Pregnancy (greater than 14 weeks) Thyroid Scrotum Sonohysterogram Carotid Doppler Arterial Doppler Upper Lower Venous Doppler Upper Lower Allergies to X-Ray Contrast Yes, notify No Barium Swallow Barium Enema (prep required) Air Contrast Barium Enema (prep required) GI Air Contrast (prep required) Small Bowel may take up to 4 hours (prep required) IVP (prep required) Arthrogram (specify joint) Bone Density/Osteoporosis Study Water Soluble Enema Other RT LT EVLT for varicose veins (686-2681) Sclerotherapy for spider veins (686-2681) PET scanning (552-2100) Vertebroplasty (552-2982) Uterine Fibroid Embolization(552-2982) Allergies to X-Ray Contrast/Dye Yes, notify No Brain Sinus Soft tissue neck Chest Abdomen (prep required) Renal stone protocol Spine with MRP Cervical Thoracic Lumbar Joint/Extremity (designate) RT LT Bilateral CT Angiography (specify area) (prep required) With Without With Without With Without With Without With IV Without IV With CT Colonography CT Enterography Screening Mammogram Diagnostic Mammogram (requires diagnosis) Ultrasound if necessary (Refer to RAPA/St. Vincent Breast Center Worsheet specific for diagnostic breast imaging prior to scheduling.) Breast Ultrasound Breast procedures-contact Breast Center for information Core biopsy, aspirations, ductogram, pre-op localization If you have any questions about yoru coverage, you may call our business office at 501-644-3914 or 888-390-7272. Other Bilateral RT LT Other **Required for Medicare Patients Only When Order CT Scans Referring Physician (Please PRINT) Physician’s Signature NPI#** CDSM HCPCS Code** AUC Modifier** CDSM Consult#**

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Page 1: Home - Radiology Associates, P.A. · Name of Patient D.O.B Home Phone Number Work Phone Number Diagnosis/Signs & Symptoms (Do Not Use “Rule Out”) Insurance Name Primary Physician

Name of Patient D.O.B

Home Phone Number Work Phone Number

Diagnosis/Signs & Symptoms (Do Not Use “Rule Out”)

Insurance Name

Primary Physician (Please PRINT) Address

Prior authorization number(s)

Fax report delivery Call immediate verbal results/fax report to follow

RAPA accepts most majorinsurance plans, includingBlue Cross Blue Shieldproducts, Aetna, CignaUnited Health Care andQualChoice QCA. Priorauthorization may berequired for HITECH orInterventional Imaging.

If you cannot meet yourappointment, please call

501-686-262124-hours

in advance.

ChestSpineOrthopaedic RT LT

Abdomen/KUBCervical Thoracic

SinusesBilateral

Acute Abd

Abdomen Flat & Upright

Lumbar

Abdomen (prep required) Kidneys (prep required)Gall Bladder (prep required) Aorta (prep required) Pelvis with endovaginal if necessary (prep required) Pregnancy (less than 14 weeks) Pregnancy (greater than 14 weeks)Thyroid Scrotum SonohysterogramCarotid DopplerArterial Doppler Upper LowerVenous Doppler Upper Lower

Allergies to X-Ray Contrast Yes, notify NoBarium Swallow Barium Enema (prep required)Air Contrast Barium Enema (prep required)GI Air Contrast (prep required)Small Bowel may take up to 4 hours (prep required)IVP (prep required)Arthrogram (specify joint)Bone Density/Osteoporosis StudyWater Soluble EnemaOther

RT LT

EVLT for varicose veins (686-2681)Sclerotherapy for spider veins (686-2681)PET scanning (552-2100)Vertebroplasty (552-2982)Uterine Fibroid Embolization(552-2982)

Allergies to X-Ray Contrast/Dye Yes, notify NoBrain SinusSoft tissue neckChestAbdomen (prep required)Renal stone protocolSpine with MRP Cervical Thoracic Lumbar Joint/Extremity (designate) RT LT BilateralCT Angiography (specify area) (prep required)

With WithoutWith Without

With Without

With Without

With IV Without IV

With

CT Colonography

CT Enterography

Screening MammogramDiagnostic Mammogram (requires diagnosis)Ultrasound if necessary(Refer to RAPA/St. Vincent Breast Center Worsheet specificfor diagnostic breast imaging prior to scheduling.)Breast Ultrasound

Breast procedures-contact Breast Center for informationCore biopsy, aspirations, ductogram, pre-op localization

If you have any questions about yoru coverage, you may call our business office at 501-644-3914 or 888-390-7272.

Other

Bilateral RT LTOther

**Required for Medicare Patients Only When Order CT Scans

Referring Physician (Please PRINT) Physician’s SignatureNPI#**

CDSM HCPCS Code** AUC Modifier** CDSM Consult#**

Page 2: Home - Radiology Associates, P.A. · Name of Patient D.O.B Home Phone Number Work Phone Number Diagnosis/Signs & Symptoms (Do Not Use “Rule Out”) Insurance Name Primary Physician

Barium Enema/Air contrast Barium Enema: requires bowel prep. If you receive bowel prep instructions from your referring physician, you may use them. Otherwise, contact RAPA for special bowel prep instructions.

IVP/GI/Small Bowel Series: Do not eat, drink or chew gum after midnight

Bone Density scan: No IV contrast, Barium Studies or NuclearMedicine studies for 72 hours prior to study. Stop calcium supplements 24-hours prior to study

HSG, Arthrograms or IVPs should be screened for allergies to X-raycontrast. In some cases pre-medication may be necessary. Recent (last 3 months) BUN and Creatinine will be necessary for patients 65 or over,insulin-dependent diabetics, or a history of renal insufficiency.

Ultrasound of Abdomen (Gall Bladder, Pancreas, Liver, Aorta) Do noteat, drink or chew gum after midnight.

Thyroid/Scrotum: No preparation required

Pelvis, Pregnancy less than 14 weeks: Patients must have a fullbladder. You should finish drinking 48 ounces of fluid 1 hour priorto your appointment time. Patients should not empty their bladderafter they have started drinking.

Pregnancy greater than 14 weeks: Patients must have a full bladder.You should drink 32 ounces of fluid 1-hour prior to appointment time.

Do not empty bladder after starting to drink.

Vascular Studies/Carotid, Arterial and Venous Doppler:No preparation required

Renal: No food 2 hours before appointment

All CT scans of the brain, neck, chest, abdomen, pelvis and CTangiography potentially involve the administration of intravenouscontrast/dye. These patients should not eat or drink 2 hours prior toappointment time. Patients scheduled for these studies should bescreened for the following as additional prep may be required:

Age 65 or over (BUN and Creatinine within the last 3 months)Insulin-dependent diabetic (BUN and Creatinine within the last3 months)History of renal insufficienty (BUN and Creatinine within the last 3 months)History of allergy to X-ray contrast (pre-medication may berequired)Diabetics on Metformin, Glugophage or Glucovance (will needreferring physicians to discontinue these meds for 48 hours following IV contrast)

CT Extremities, Joints, and Spine generally do not require IV contrastand therefore no special preparation is necessary.

Screening or Diagnostic: No powder, perfume or deodorant inunderarm area

History of previous mammograms: When? Where?

Breast Ultrasound: No preparation required

For Aspirations/Biopsies: contact office for special instructions.

The Contact Numbers listed on the front page will be able to supplyany necessary preparation instructions and/or information necessary.

DOCTORSPLAZA

SEARS AUTO CENTERI-630

TARGET SHOPPING CENTER

ST. VINCENT CIRCLE (formerly West Capital Avenue)

GUESTHOUSE

GOLFCOURSE

ST. VINCENTINFIRMARYMEDICALCENTER

PAR

KIN

G D

ECK

MARKHAM STREET

S. UN

IVER

SITY A

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DOCTORSBUILDING

WestEntrance

MainEntrance

SURGERYCENTER


Reg Date of Name D.O.B Medical council Address

CORBY BOROUGH COUNCIL SEVERE WEATHER EMERGENCY … · Basic d etails 1. Client name 2. Contact phone number 3. Gender Male Female 4. D.O.B. 5. Nationality 6. Ethnic group White British

1 Curriculum Vitae 1. Personal Details: Name: Howard Steele (d.o.b.

S.No Roll no Name of applicant D.O.B Father’s name ...164.100.158.72/writereaddata/list of Pharmacist 1.pdf · S.No Roll no Name of applicant D.O.B Father’s name Correspondence

Patient s Name: Date - jaxhealth.com circle YES or NO to the following questions: ... Designated Representative ... Patient Name: D.O.B Account #:

Name: Date: Cell Phone: Home Phone: D.O.B. S.S.N.# Date: Cell Phone: Home Phone: Email: ... J. Agent represents to Licensee that: (1) ... material breach of this Agreement or by negligent

Real Name: Charles John Huffam Dickens D.O.B: 7 February 1812

1st YEAR MBBS 2015-16hbtmc.edu.in/wp-content/uploads/2020/02/student...1st_year_mbbs_2015-16 sr.no. student name gender category validity report status phone no d.o.a d.o.b. 1 phad

ROLL. NO D.O.B. CASTE ALOTTED RAILWAY CATEGORY … list of allotment of...roll. no d.o.b. caste alotted as railway category candidates name & address training centre reporti ng data

FIRST NAME LAST NAME EMAIL FIRM NAME CELL PHONE PHONE NBR · FIRST NAME LAST NAME EMAIL FIRM NAME CELL PHONE PHONE NBR B. Scott Ware [email protected] B.Scott Ware Appraisal & Revie

Short Name Org Name Position PHONE TYPE PHONE Employee … · 2018-06-23 · Short Name Org Lv2Name Name Employee First Name Employee Middle Position Official Title PHONE TYPE PHONE

Sr. Name Designation D.O.B D.A O Period of ACRs …hppwd.gov.in/Links/ACR Status of Minist. Staff March 2013.pdf · Name Designation D.O.B D.A O Period of ACRs Remarks ... 5 Lal Singh

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MARRIAGE REPORT Name- D.O.B- TIME- PLACE

Sr. No. Full Name D.O.B Address No Number...Sr. No. Ward No Full Name D.O.B Address Mobile Number Differently Abled Road Name Landmark Business Type 1 14 Aabid Baig Aamad Baig 14-10-62

JNV Where Admission is State State Name Dist. District Name … · 2019. 7. 8. · State State Name Dist. District Name Candidate Name Roll No. Father Name D.O.B JNV Where Admission

Phone Routing Phone Routing Name Number Symbol …Phone Routing Phone Routing Name Number Symbol Room/Bldg Name Number Symbol Room/Bldg

Name: Phone: Relationship: Others Authorized to Pick Up ... · Name: Phone: Relationship: Others Authorized to Pick Up Name: Phone: Relationship: Child's Name: Address: Home Phone:

 · Web viewFirst name Last name Phone number Email address First name Last name Phone number Email address First name Last name Phone number Email address First name Last name

Sarah COUNTY LAST NAME FIRST NAME LENDER NAME PHONE # 2nd PHONE

C a m Service Rank Name No. Regt. Origin Died Age/D.o.B ...€¦ · Rank Name Service No. Regt. Origin Died Age/D.o.B Buried Additional Information. C a m p s Lt. Col. Hugonin. Frances

FINANCIAL DISCLOSURE / AFFIDAVIT OF INDIGENCY · FINANCIAL DISCLOSURE / AFFIDAVIT OF INDIGENCY ... Case No. Phone ( ) ... D.O.B. Relationship Name 3) D.O.B. Relationship 2) 4) III

pediatric-case-history… · HEARING LTD. MEDICAL Child's Name: Referring Physician: Concern: Otological History: PEDIATRIC CASE HISTORY D.O.B.: Mother's Name: Father's Name:

S.No Roll no Name of applicant D.O.B Father’s name ... of Pharmacist 1.pdfS.No Roll no Name of applicant D.O.B Father’s name Correspondence address 1. 00001 Amit kumar 10/02/1994

Personal Data Name : Abby Zacky D.O.B : Dec 2 nd 1983 CP : 08568777225

Constellation Financial...Constellation Financial & Wealth Management Services III CLIENT: First Name & Initial Last Name: Social Security No. D.O.B. Best Phone No. Occupation: Best

Roll no. Name of Candidate Parents Name Gender Eligiblity ...admission.du.ac.in/upload_ugent2017/bulletin/BELED.pdf · Roll no. Name of Candidate Parents Name Gender Eligiblity D.O.B

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FAMOUS BRITS. John Lennon Name: John Winston Lennon Name: John Winston Lennon D.O.B : 9/10/40 D.O.B : 9/10/40 Death: 8/12/80 Death: 8/12/80 Born and raised

LIST OF EMPLOYEES HAVING D.O.B IN JANUARY … OF EMPLOYEES HAVING D.O.B IN JANUARY S.No Name and Designation Unit Date of Birth S./Sh./Smt./ 1. Haridass, Asstt.Floor Supervisor HSV

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