Imaging Study Order Checklist Items & Form Links

Please be sure all items below are complete for the study of interest BEFORE submitting your order

Please allow a minimum of one week's time for insurance pre-authorization

Click this link for the latest TCRHCC Radiology Department News

 

Imaging Study Primary Order Form (complete/submit
for all orders)
Secondary Forms
(complete & submit with the "Primary Order Form", as applicable)
Patient Instructions & Information 
(review with/distribute to patient, as applicable)
Other Checklist Items  
(be sure to submit these items with your order, as applicable)
For Your Convenience╔.
ICD-9 Codes Image Ordering Guides
Computed Tomography (CT)

Primary Order Form
(complete for ALL imaging studies and procedures)

CT Xay Contraindications Release Form CT Consent Form* Patient Instructions *Contrast Consent and
BUN & Creatinine for
all IV Contrast Studies
ALL Studies:
Health Summary
Medication List
Previous Relevant
Imaging Studies

Clinical Notes (include diagnosis and ICD-9 Code)
Insurance Information
Lab results (IV contrast studies)
 Referring provider NPI # and information (if not on file complete & submit form--see link below)

Frequently used ICD-9 Codes for Radiology CT/MRI Ordering Guide CT Ordering & Precertification Guide
  Magnetic Resonance Imaging (MRI) MRI Screening Form MRI Contraindications
(declines HCG or pregnant patient)
MRI Contrast Consent Patient Instructions MRI Patient
Information Sheet
*Contrast Consent and
BUN & Creatinine for
all IV Contrast Studies
CT/MRI Ordering Guide
Magnetic Resonance Imaging (MRI) Breast MRI Screening Form MRI Breast Questionnaire MRI Contraindications (declines HCG or pregnant patient) MRI Contrast Consent* Patient Instructions MRI Patient
Information Sheet
*Contrast Consent and
BUN & Creatinine for
all IV Contrast Studies
Breast Imaging Ordering Guide
  Ultrasound (US)   Patient Instructions   Ultrasound Ordering Guide Breast Imaging Ordering Guide
  Echocardiogram                      
  Vascular Ultrasound                      
Fluoroscopy
 (arthrogram & GI studies)
        Patient Instructions          
  Mammography Mammography Breast Evaluation
(note: breast exam is optional)
Mammography Consent Form Patient Instructions   Breast Imaging Ordering Guide
  Bone Densitometry (DEXA) DEXA Questionnaire       Referring Provider
Information Form
       
  Xray CT Xray Contraindications Release Form X-Ray Order Form        
  Interventional Radiology IR Order Form            

 

Additional Patient Information and Instructions

MRI Information