Ultrasound Scheduling Ultrasound Scheduling In order to process the appointment, please complete all of the information below. A coordinator will schedule an appointment as quickly as possible. Please ensure the accuracy of the information provided.Patient Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Primary Phone(Required)Secondary PhoneRequesting Physician/Provider(Required) Physician Full Name Clinic Contact Name(Required) Full NamePhysician/Clinic Phone(Required)Authorization Number(Required) Insurance(Required) Insurance Policy Number(Required) Procedure(Required)Renal Ultrasound with DopplersUltrasound Head NeonatalUltrasound Neck Soft Tissue (Right/Left/Bilateral)Ultrasound Needle PlacementUltrasound PancreasUltrasound Pelvic Comp Non-ObUltrasound Pelvic Ltd Non-ObUltrasound Preg 1st Tri Add GeUltrasound Preg 1st Tri SingleUltrasound Preg After 1st AddUltrasound Preg After 1st SingUltrasound Preg Complete AddUltrasound Preg Complete 1st GUltrasound Preg F/U Re-EvaluatUltrasound Preg LtdUltrasound Preg TransvaginalUltrasound Renal Complete (Right/Left/Bilateral)Ultrasound Renal Ltd (Right/Left/Bilateral)Ultrasound ScrotumUltrasound SpleenUltrasound ThyroidUltrasound TransrectalUltrasound TransvaginalUS Abd Aorta CompleteUS Abd Aorta Non-Screening CompUS Abd CompleteUS Abdomen Complete With DopplerUS Biopsy – ThyroidUS Breast or both (Right/Left/Bilateral)US Chest MediastinumUS Extremity Non VascularUS Gallbladder LiverUS Gallbladder LiverUS Gallbladder/Liver W/DopplerUS Liver DopplerDiagnosis Code(Required) Does the patient have Medicare?(Required) Yes No Has the patient previously had this exam?(Required) Yes No MEDICARE WILL ONLY PAY FOR THIS EXAM ONCE IN A BENEFICIARY'S LIFETIME. IF PATIENT CHOOSES TO HAVE EXAM PERFORMED A NOTICE OF NON-COVERAGE WILL NEED TO BE SIGNED BY THE PATIENT.The patient must have nothing to eat or drink 8 hours before the exam.Additional Procedure (If Applicable)No Additional ProcedureRenal Ultrasound with DopplersUltrasound Head NeonatalUltrasound Neck Soft Tissue (Right/Left/Bilateral)Ultrasound Needle PlacementUltrasound PancreasUltrasound Pelvic Comp Non-ObUltrasound Pelvic Ltd Non-ObUltrasound Preg 1st Tri Add GeUltrasound Preg 1st Tri SingleUltrasound Preg After 1st AddUltrasound Preg After 1st SingUltrasound Preg Complete AddUltrasound Preg Complete 1st GUltrasound Preg F/U Re-EvaluatUltrasound Preg LtdUltrasound Preg TransvaginalUltrasound Renal Complete (Right/Left/Bilateral)Ultrasound Renal Ltd (Right/Left/Bilateral)Ultrasound ScrotumUltrasound SpleenUltrasound ThyroidUltrasound TransrectalUltrasound TransvaginalUS Abd Aorta CompleteUS Abd Aorta Non-Screening CompUS Abd CompleteUS Abdomen Complete With DopplerUS Biopsy – ThyroidUS Breast or both (Right/Left/Bilateral)US Chest MediastinumUS Extremity Non VascularUS Gallbladder LiverUS Gallbladder LiverUS Gallbladder/Liver W/DopplerUS Liver DopplerDiagnosis Code(Required) Does the patient have Medicare?(Required) Yes No Has the patient previously had this exam?(Required) Yes No MEDICARE WILL ONLY PAY FOR THIS EXAM ONCE IN A BENEFICIARY'S LIFETIME. IF PATIENT CHOOSES TO HAVE EXAM PERFORMED A NOTICE OF NON-COVERAGE WILL NEED TO BE SIGNED BY THE PATIENT.The patient must have nothing to eat or drink 8 hours before the exam.Additional Procedure 2 (If Applicable)No Additional ProcedureRenal Ultrasound with DopplersUltrasound Head NeonatalUltrasound Neck Soft Tissue (Right/Left/Bilateral)Ultrasound Needle PlacementUltrasound PancreasUltrasound Pelvic Comp Non-ObUltrasound Pelvic Ltd Non-ObUltrasound Preg 1st Tri Add GeUltrasound Preg 1st Tri SingleUltrasound Preg After 1st AddUltrasound Preg After 1st SingUltrasound Preg Complete AddUltrasound Preg Complete 1st GUltrasound Preg F/U Re-EvaluatUltrasound Preg LtdUltrasound Preg TransvaginalUltrasound Renal Complete (Right/Left/Bilateral)Ultrasound Renal Ltd (Right/Left/Bilateral)Ultrasound ScrotumUltrasound SpleenUltrasound ThyroidUltrasound TransrectalUltrasound TransvaginalUS Abd Aorta CompleteUS Abd Aorta Non-Screening CompUS Abd CompleteUS Abdomen Complete With DopplerUS Biopsy – ThyroidUS Breast or both (Right/Left/Bilateral)US Chest MediastinumUS Extremity Non VascularUS Gallbladder LiverUS Gallbladder LiverUS Gallbladder/Liver W/DopplerUS Liver DopplerDiagnosis Code(Required) Does the patient have Medicare?(Required) Yes No Has the patient previously had this exam?(Required) Yes No MEDICARE WILL ONLY PAY FOR THIS EXAM ONCE IN A BENEFICIARY'S LIFETIME. IF PATIENT CHOOSES TO HAVE EXAM PERFORMED A NOTICE OF NON-COVERAGE WILL NEED TO BE SIGNED BY THE PATIENT.The patient must have nothing to eat or drink 8 hours before the exam.Additional Procedure 3 (If Applicable)No Additional ProcedureRenal Ultrasound with DopplersUltrasound Head NeonatalUltrasound Neck Soft Tissue (Right/Left/Bilateral)Ultrasound Needle PlacementUltrasound PancreasUltrasound Pelvic Comp Non-ObUltrasound Pelvic Ltd Non-ObUltrasound Preg 1st Tri Add GeUltrasound Preg 1st Tri SingleUltrasound Preg After 1st AddUltrasound Preg After 1st SingUltrasound Preg Complete AddUltrasound Preg Complete 1st GUltrasound Preg F/U Re-EvaluatUltrasound Preg LtdUltrasound Preg TransvaginalUltrasound Renal Complete (Right/Left/Bilateral)Ultrasound Renal Ltd (Right/Left/Bilateral)Ultrasound ScrotumUltrasound SpleenUltrasound ThyroidUltrasound TransrectalUltrasound TransvaginalUS Abd Aorta CompleteUS Abd Aorta Non-Screening CompUS Abd CompleteUS Abdomen Complete With DopplerUS Biopsy – ThyroidUS Breast or both (Right/Left/Bilateral)US Chest MediastinumUS Extremity Non VascularUS Gallbladder LiverUS Gallbladder LiverUS Gallbladder/Liver W/DopplerUS Liver DopplerDiagnosis Code(Required) Does the patient have Medicare?(Required) Yes No Has the patient previously had this exam?(Required) Yes No MEDICARE WILL ONLY PAY FOR THIS EXAM ONCE IN A BENEFICIARY'S LIFETIME. IF PATIENT CHOOSES TO HAVE EXAM PERFORMED A NOTICE OF NON-COVERAGE WILL NEED TO BE SIGNED BY THE PATIENT.The patient must have nothing to eat or drink 8 hours before the exam.Additional Procedure 4 (If Applicable)No Additional ProcedureRenal Ultrasound with DopplersUltrasound Head NeonatalUltrasound Neck Soft Tissue (Right/Left/Bilateral)Ultrasound Needle PlacementUltrasound PancreasUltrasound Pelvic Comp Non-ObUltrasound Pelvic Ltd Non-ObUltrasound Preg 1st Tri Add GeUltrasound Preg 1st Tri SingleUltrasound Preg After 1st AddUltrasound Preg After 1st SingUltrasound Preg Complete AddUltrasound Preg Complete 1st GUltrasound Preg F/U Re-EvaluatUltrasound Preg LtdUltrasound Preg TransvaginalUltrasound Renal Complete (Right/Left/Bilateral)Ultrasound Renal Ltd (Right/Left/Bilateral)Ultrasound ScrotumUltrasound SpleenUltrasound ThyroidUltrasound TransrectalUltrasound TransvaginalUS Abd Aorta CompleteUS Abd Aorta Non-Screening CompUS Abd CompleteUS Abdomen Complete With DopplerUS Biopsy – ThyroidUS Breast or both (Right/Left/Bilateral)US Chest MediastinumUS Extremity Non VascularUS Gallbladder LiverUS Gallbladder LiverUS Gallbladder/Liver W/DopplerUS Liver DopplerDiagnosis Code(Required) Does the patient have Medicare?(Required) Yes No Has the patient previously had this exam?(Required) Yes No MEDICARE WILL ONLY PAY FOR THIS EXAM ONCE IN A BENEFICIARY'S LIFETIME. IF PATIENT CHOOSES TO HAVE EXAM PERFORMED A NOTICE OF NON-COVERAGE WILL NEED TO BE SIGNED BY THE PATIENT.The patient must have nothing to eat or drink 8 hours before the exam.CommentsThis field is for validation purposes and should be left unchanged.