Service Order Form

Service Order Form
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender
Select One
Patient or Facility Address
Address, including Suite/Apartment/Room Number
City
State
Zip
Patient or Facility Contact Number
Please enter a valid phone number.
Alternate Contact Number
Please enter a valid phone number.
If you already have all required documents — including the completed prescription, patient information, and ordering physician details — you may skip ahead to our Fast Form Submission section - At the Bottom
- ChestAbdomen (KUB)PelvisSacrum/CoccyxSpine/CervicalSkullFacial BonesSpine/ThoracicNasal BonesOrbitsSpine/LumbarSinusesMandibleShoulderClavicleScapulaHumerusElbowForearmWristHandFingerHipFemurKneeTibia/FibulaAnkleFootToeOther
- Views (Right/Left)
- Routine or Not Medically Necessary:
  Medicare Part B does not cover X-rays done for routine or screening purposes—such as chest X-rays for pre-surgery clearance or nursing home admission—unless there's a specific medical reason and symptoms documented by a provider. Coverage requires that the X-ray be medically necessary to diagnose or treat an illness or injury, not just for general screening or protocol.
- Use our ICD10 finder for the most common diagnosis codes. Simply search in the text box, use the dropdown and select applicable codes.
  
  If your diagnosis is not listed please insert in "ICD10 - Not Listed" box.
- Common ICD10
- ICD10 - Not Listed
- Mobile X-rays must be ordered by a licensed medical provider. This includes doctors (MD or DO), nurse practitioners, and physician assistants. Facilities like nursing homes, assisted living, home health, or hospice can request an X-ray, but they must have a doctor’s signed order. Patients and family members can ask for one, but a provider must approve it before it can be scheduled or billed to insurance.
  Results will be FAXed to both the ordering agency and referring provider.
- Provider Full Name
  
  First NameLast Name
- Facility or Group Name
- NPI
- Phone Number
- FAX Number
- Radiology Reports will be FAXed to both Ordering agency/facility and ordering provider.
- Medicare Part BHumanaPeople's HealthUnitedOther
- Insurance Card - Front
  
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- Insurance Card - Back
  
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- Member ID
- Group Number
- Policy Holder Name & Date of Birth (if different)
- Driving Directions, Access Codes, Notifications
- If you already have referral paperwork or documentation that includes all required information, you do NOT need to complete each section of this form.
  
  ✔️ You can upload a photo or PDF just use the File Upload option below or at the bottom of the form
  ✔️ Or fax it to us directly 504.888.6474
  
  We’ll review your submission and follow up as needed. Thank you!
- Fast Submission Option
  
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- Ordering Provider Email
- Should be Empty: