Radiology Request- Diagnostic X-Ray

Scheduling 540-332-4400 Fax 540-332-4490

Patient Name ______________________ DOB _______ Weight _____ Appt. Date/Time _______________
Patient Address ____________________________________________ Phone _______________________
Insurance _________________________ Policy #_________________ Group # _____________________
Ins. Subscriber/DOB ________________________________________ Relation to Patient _____________
Pre-Auth Required: Y ___ N ___ Pre-Auth# ______________________ Packet Given: Y ___ N ___
Reason for Exam _______________________________________________________________________
Exam CPT Exam CPT
Abdomen Complete 74019 AP Pelvis Standing ____ Supine ____ 72170
Abdomen Complete w/ PA Chest 74022 Ribs-Bilateral with PA Chest 71111
Ankle Complete L __ R __ 73610 Ribs with PA Chest L __ R __ 71101
Chest PA and Lateral 71046 Shoulder Complete L __ R __ 73030
Cervical Spine Complete 72050 Tibia/Fibula L __ R __ 73590
Cervical Spine 2-3 Views 72040 Thoracic Spine AP, Lat, Swimmer’s View 72072
Elbow Complete L __ R __ 73080 Thoracic Spine AP & Lateral 72070
Femur 1 view L __ R __ 73551 Thoraco-Lumbar Spine (not entire T/L Sp) 72080
2+ views L __ R __ 73552 Scoliosis- Thoracic lumbar Spine 72082
Finger(s)(3 or more, order hand)L __ R __ 73140 Toe(s) (3 or more, order foot) L __ R __ 73660
Specify finger(s) _____________ Specify toe(s) _____________
Feet- AP Bilateral Arthritis 1 View 77077 Wrist Complete L __ R __ 73110
Foot Complete L __ R __ 73630 Fluoro Exams
Forearm L __ R __ 73090 Barium Enema 74270
Hand/Wrist- Bilateral Arthritis 2 Views 73120 Barium Enema with Air Contrast 74280
Hand Complete L __ R __ 73130 Barium Enema with Gastroview 74270
Hips- Bilateral with AP Pelvis 73523 Barium Swallow with PA Chest 74220
Hip with AP Pelvis L __ R __ 73502 Modified Barium Swallow (with Speech) 74230
Humerus L __ R __ 73060 GI Series with Air Contrast 74247
IVP with Nephrotomography 74415 GI with Air Contrast with Small Bowel 74249
Knee Complete L __ R __ 73562 Hysterosalpingogram 74740
KUB 74018 Ordering doctor to perform test?Y __ N __ 58340
Sitz Marker Study 74018 Shoulder Arthrogram L __ R __ 73040
To be performed with MRI? Yes ___ No ___ 23350
If yes, also pre-cert code 73222
Lumbosacral Spine Complete 72110 Small Bowel Series 74250
Special instructions:

Lumbosacral Spine 2-3 Views 72100 Voiding Cystourethrogram 74455

Standing _____ Supine _____ 51600
Special instructions:

Other Exam: (Please specify)

Wet Read Y N Patient leave if negative? Y N Results will be faxed

Physician Signature_________________________________ Date__________________ Time _________
January 2018