PATIENT NAME:

D.O.B. MM/DD/YEAR SS

PATIENT ADDRESS:

PATIENT PHONE #

ORDERING PHYSICIAN / CLINIC

PHONE # FAX #

PIMARY INSURANCE:

ID #

AUTHORIZATION #

DIAGNOSIS/REASON FOR REFERRAL

	CAROTID ULTRASOUND
	Carotid Doppler (Bilateral) Carotid Duplex (Bilateral)

	ECHOCARDIOGRAM
	Echo 2D M-Mode Cardiac Doppler Colorflow Doppler

LOWER EXTREMITIES
Venous Doppler/ Duplex	Arterial Doppler/Duplex
Bilateral Study  Unilateral Study  L    R	Bilateral Study  Unilateral Study  L     R

ABDOMINAL STUDIES	RETROPERITONEAL
Liver	Renal
Gallbladder	Aorta
Spleen	Pancreas

UPPER EXTREMITIES
Venous Doppler/ Duplex	Arterial Doppler/Duplex
Bilateral Study  Unilateral Study  L     R	Bilateral Study  Unilateral Study  L    R

OTHER ULTRASOUND STUDIES Pelvic Bladder Prostate Breast Testicular Thyroid

A portable diagnostic test is being ordered as the patient would find it physically and/or psychologically taxing outside the home, because of advanced age and physical limitations. This test and/or treatment is medically necessary for the diagnosis and treatment of this patient.

I hereby assign medical benefits for the procedures indicated to the provider of service, that the information given by me in applying for payment under Title XVII of the Social Security Act is correct. I agree that a copy of this form is as valid as an original. I certify the procedures that have been checked off have been performed on me to the best of my knowledge. By signing below, I agree to be financially responsible for any and all unpaid balances that are not paid by my insurance company. I further authorize the release of any medical notes and/or test results which may be necessary to insure payment. Further, I authorize any holder of medical or other information about me to release to HCFA, its intermediaries, provider or carriers, any information required to perform this exam, manage my healthcare needs and to insure payment of above services.