Patient Name
First Name
Last Name
Patient Date of Birth
/
Month
/
Day
Year
Date
Ordering Physician
Last Name, First Name
Ordering Physician FAX Number
Ordering Physician Phone Number
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Ankle
Chest
Elbow
Foot
Forearm
Hand
Hip
Knee
KUB/Abdomen
Pelvis
Ribs
Shoulder
Skull
Spine/Cervical
Spine/Lumbar
Spine/Thoracic
Tibia/Fibia
Wrist
Other
Location
Right
Left
Bilateral
Reason for Exam
Supporting Documents
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Ordering Health Facility/Agency
Facility Contact Name
Facility Phone Number
Facility Fax Number
Email
example@example.com
Additional Notes
Did your supporting documents include the patient's location information?
*
YES
NO
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Patient Address
Apt/Room #
City
State
Zip Code
Additional Information - Location Notes/Access Codes, etc.
Patient Location Type
Residential Home
Assisted Living
Nursing Home
Skilled Facility
Did your supporting documents include the Patient's Insurance Information?
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Did your supporting documents include the Patient's Insurance Information?
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Primary Insurance
Humana
Medicare Part B
People's Health
Other
Insurance Member Number
Group Number
Responsible Party
First Name
Last Name
Relationship to Patient
Self
Other
Responsible Party Billing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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