CT Chest, Abdomen and Pelvis Imaging Request

1 First Name:Middle I nitial:Last Name:DOB (mm/dd/yyyy):Gender:MaleFemaleStreet A ddress:Apt #:City:State:Zip:Cell P hone:Primary Con tact:HomeCellHealth Plan:Member ID:Group I D:First Name:Last Name:Primary S pecialty:TIN:NPI:Physician P hone:Physician Fax :Address:Suite #:City:State:Zip:Office Co ntact:Ext:Contact E mail:First Name:Last Name:Group/Site Name:Primary S pecialty:TIN:NPI:Site Phone:Site Fax:Address:Suite #:City:State:Zip:CT A BD:741507416074170CT P ELVIS:721927219372194CT A BD an d P ELVIS:741767417774178CT chest :712507126071270 CTA chest :71275 Other:Page 1 of 3 Patient/MemberOrdering ProviderHome P hone:Facility/SiteCheck al lapplicableCPT Cod es:ProcedureCONFIDENTIALITY NOTICE: This fax transmission, and any documents attached to it may contain confidential or privileged information subject to privacyregulations such as the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

2 This information is intended only for the use of the recipient(s) named above. If you are not the intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby notified that anydisclosure, copying, distribution or use of any of the information contained in or attached to this transmission is STRICTLY PROHIBITED. If you havereceived this transmission in error, please immediately notify eviCore healthcare and destroy the original transmission and its attachments without savingthem in any chest , Abdomen and Pelvis Imaging RequestFor NON-URGENT requests, please fax this completed document along with medical records, Imaging , tests, there are any inconsistencies with the medical office records, please elaborate in the comment section. Failure to provide all relevant information may delay the Request authorization an submit to site the on located portal provider the into log also may You section.

3 Forms Fax and Guidelines the under on found be can numbers fax and .URGENT (same day) REQUESTS MUST BE SUBMITTED BY PHONE. eviCore healthcare | | 400 Buckwalter Place Blvd Bluffton, SC 29910 | Diagnosis, if known or rule out: ICD-10 Codes: Date of last visit:1. Date of most recent office visit or other contact with physician:Don't KnowPhone call with office staff Phone call with physician Don't Know3. Is abodminal or pelvic pain present?YesNoDon't Know4. Where is the location of pain? Above the Umbilicus or below?AboveDoes not have painDon't KnowBoth5. Is there left lower quadrant pain?YesNoDon't Know6. Has there been abdominal or Pelvis surgery within the past year?YesNoDon't Know7. Is fever present?YesNoDon't Know8. Is there an elevated white blood cell count?YesNoDon't Know9. Is this to evaluate a hernia?YesNoDon't KnowYesNoDon't Know11.

4 Has there been unexplained or unintentional weight loss?YesNoDon't Know12. Is there a history of diverticulitis?YesNoDon't Know13. Has treatment with antibiotics been done in the past week?YesNoDon't Know14. Is this for cancer diagnosis?YesNoDon't Know15. Is there evidence of cancer in the chest ?YesNoDon't Know16. Is there a new nodule or mass on chest x-ray or Imaging study?YesNoDon't KnowYesNoDon't Know18. Has a chest CT been done within the past year?YesNoDon't Know19. Is chest pain present?YesNoDon't KnowPage 2 of 3 Diagnosis2. Type of most recent documented contact with physician?HospitalOffice visitEmailOther10. Are there unclear findings of previous Imaging studies (CT, MRI,Ultrasound, X-ray?)17. Was a chest x-ray done within the last 4 weeks and read by aradiologist?Clinical Information BeloweviCore healthcare | | 400 Buckwalter Place Blvd Bluffton, SC 29910 | 20.

5 Has a D-dimer been d one?NormalTest n ot doneAbnormalDon't KnowAdditional In formation/Comments:Who i s m aking th is r equest? O rdering P hysician Facility O ther:Print Name:Title: M D RN LP N P A NP Other:Signature:Date:Page 3 of 3 SubmitterClinical InformationeviCore healthcare | | 400 Buckwalter Place Blvd Bluffton, SC 29910 |