Banner.

Date: 11/08/22 Time: 7:35 PM Page: 04 To 14808016204 From: +18662425309 No ID
Banner.
Imaging
Central Scheduling: 480.610.7400 I Fax Scheduling: 480.610.7401 www.BannerHealth.com/Imaging Maricopa County & Medicaid NPI: 1770139958 Banner Imaging Tax ID: 90-1249771 Pinal County NPI: 1841846920 Associated Valley Radiologists, LLC Tax ID: 831984436NPI: 1932683257

Please present this imaging order at time of exam. See maps on back.
(Last)
(First)
(MR
DOB*
Date*

MonthDayYear
Date
Home Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Insurance
Insurance ID
Insurance Auth
Referrer Name
Referrer Contact
Signature

Clear
Type option 1Type option 2Type option 3Type option 4
Office Phone
Format: (000) 000-0000.
Office Fax
SCHEDULING INSTRUCTIONS
Please Obtain Authorization (Include Patient PHI, H& P and Insurance Card)

Please Call Patient to Schedule Exam
REPORT/IMAGE INSTRUCTIONS
Date

MonthDayYear
Date
Exam
to Location
Location
Clinical History/ICD 10 Code(s)
MAMMOGRAPHY
Digital Screening Mammogram Ultrasound, if indicated (please check one) asymptomatic patient/routine exam diffuse/general breast pain family history, no clinical concern previous biopsy, no clinical concern previous mastectomy/lumpectomy, no clinical concern
BREAST PROCEDURES
Cyst Aspiration Core Blopsy w/MRI w/USw/Stereow/3D Tomo Ductogram Needle Localization w/US w/Mammo

laugmentation implants, no clinical concern fibrocystic changes expressed nipple discharge

ULTRASOUND (Transvaginal/Dappler, indicated Breast (Mammogram, if indicated) palpable lump/thickening (locate on diagram) focal pain (locate on diagram) short interval follow up (bring prior films) Abdomen

Body Composition (self pay) MRI (X-rays and CAD, if indicated) Breast W/WO Contrast-Bilateral Breast W/WO Contrast-Bilateral with implants MRI Guided Needle Core Biopsy MRI Guided Pre-op Needle Localization Abdomen Open/Short W/WO Contrast* Abdomen/Pelvis WO Contrast Per Radiologist* Pelvis Arthrogram *incides IStat creating ifind
Per Radiologist*
Digital Diagnostic Mammogram3D Ultrasound, if indicated (please check one) palpable lump or thickening (locate on diagram) focal pain (locate on diagram) Ispontaneous nipple discharge previous lumpectomy (malignant) previous mastectomy, no clinical concern ishort interval follow-up (bring prior films)

Bony Pelvis Brain Spine C T L Other:
Other
Per Radiologist
Diagnostic Evaluation3D (Consultation to include digital Imammography, ultrasound & interventional procedures as indicated)

W Contrast* W/WO Contrast* WO Contrast Per Radiologist Arthrogram but creativis if Indicated
Other
RIGHT LEFT Illustrate: O=Lump X=Pain
Other
X-RAY
DXA/BONE DENSITY
LEFT RIGHT
DXA/Bone Densitometry DXA/Bone Densitometryw/Vertebral Fracture Assessment
Other
Should be Empty:

Banner.

Imaging

SCHEDULING INSTRUCTIONS

REPORT/IMAGE INSTRUCTIONS

MAMMOGRAPHY

BREAST PROCEDURES

X-RAY

DXA/BONE DENSITY

LEFT RIGHT