Diagnostic Imaging Referral Form - June 2014 - …

1 Diagnostic Imaging Referral june 2014. 3$7,(17. Patient Name _____ DOB_____ EPIC# _____. Home Phone #_____ Work Phone # _____ Cell Phone # _____. Please circle best number to reach patient during daytime hours. Exam Requested _____. (;$0. Indications / Diagnosis _____. Patient History_____ ICD 9 _____. Radiologist may modify the order per protocol to meet the clinical needs of the patient. By checking this box, I acknowledge I have reviewed the standard operating procedures (SOP) used by Sutter Imaging . Insurance Carrier / Medical Group _____ ID # _____. ,16. Insurance Phone # _____ Prior Authorization # (if needed)_____. Ordering Provider _____ Signature Required X _____. 3529,'(5. Copy Reports to (Names and Locations) _____. Date Completed _____ Phone # _____ Fax # _____. PATIENT INSTRUCTIONS.)))

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ppt Date _____ Appt Time _____ am / pm This document contains con dential patient information.]]]]]

3 Please notify us immediately if you are not the intended recipient. LOCATIONS. Sutter Imaging 29th Street Sutter Imaging Carmichael Sutter Imaging Lincoln Sutter Imaging South 1020 29th Street, Suite 120 6620 Coyle Avenue 685 Twelve Bridges Dr. 8118 Timberlake Way Sacramento, CA 95816 Suite 110 Suite A Suite 110. T: (916) 453-9999 Carmichael, CA 95608 Lincoln, CA 95648 Sacramento, CA 95823. F: (916) 784-2670 T: (916) 961-4910 T: (916) 408-5448 T: (916) 681-8852. Sutter Imaging Alhambra F: (916) 784-2670 F: (916) 408-5454 F: (916) 784-2670. 1201 Alhambra Blvd., Suite 140 Sutter Imaging Davis Sutter Imaging Rancho Sutter Imaging Vacaville Sacramento, CA 95816 2020 Sutter Place Cordova 770 Mason Street T: (916) 731-7782 Davis, CA 95616 11121 Sun Center Drive, Suite A Vacaville, CA 95688. F: (916) 731-7781 T: (530) 747-5030 Rancho Cordova, CA 95670 T: (707) 427-4900.

4 Sutter Imaging Amador F: (530) 747-5031 T: (916) 861-8304 F: (707) 454-5922. 100 Mission Boulevard Sutter Imaging Elk Grove F: (916) 852-7910 Sutter Imaging Vallejo Jackson, CA 95642 8170 Laguna Blvd., Suite 112 Sutter Imaging Roseville II 100 Hospital Drive T: (209) 223-7560 Elk Grove, CA 95758 2 Medical Plaza, Suite 105 Vallejo, CA 94589. F: (209) 223-7548 (877) 515-0053 Scheduling Roseville, CA 95661 T: (707) 427-4900. T: (916) 691-5922 Direct T: (877) 515-0053 Scheduling F: (707) 551-3612. Sutter Imaging Auburn F: (916) 865-1491 T: (916) 865-1462 Direct Sutter Imaging Woodland 3123 Professional Drive Sutter Imaging Fair eld F: (916) 865-1491 475 Pioneer Ave., Suite 100. Suite 100. Auburn, CA 95603 2700 Low Court Sutter Imaging Roseville Woodland, CA 95776. T: (530) 888-8878 Fair eld, CA 94534 Parkway T: (530) 406-5616.

5 F: (530) 887-8255 T: (707) 432-2500 1640 E. Roseville Parkway F: (530) 406-5618. F: (707) 432-2599 Suite 100 Sutter Imaging Yuba City Sutter Imaging Auburn Faith 11815 Education Street Sutter Imaging Folsom I Roseville, CA 95661 440 Plumas Boulevard Auburn, CA 95602 1655 Creekside Drive T: (916) 784-2277 Yuba City, CA 95991. T: (530) 888-4535 Folsom, CA 95630 F: (916) 784-2670 T: (530) 749-3301. F: (530) 887-8255 T: (916) 984-0739 Sutter Imaging Roseville PET F: (530) 749-3496. F: (916) 784-2670 2241 Douglas Boulevard Sutter Imaging Campus Commons Sutter Imaging Folsom II Suite 110. 2 Scripps Drive, Suite 110 1661 Creekside Drive Roseville, CA 95661. Sacramento,CA 95825 Folsom, CA 95630 T: (916) 783-8900. T: (916) 929-3393 T: (916) 984-0739 F: (916) 789-1550. F: (916) 784-2670 F: (916) 784-2670 Sutter Imaging Sutter Imaging Capitol Pavilion Sutter Imaging Greenback Sacramento 2725 Capitol Ave.

6 , Suite 104/106 5767 Greenback Lane 3161 L Street Sacramento, CA 95816 Sacramento, CA 95841 Sacramento, CA 95816. T: (877) 515-0053 Scheduling T: (916) 865-1079 T: (916) 453-9999. T: (916) 262-9301 Direct F: (916) 865-1085 F: (916) 784-2670. F: (916) 865-1491. SERVICES BY LOCATION. Location CT MRI General X-Ray Fluoroscopy Ultrasound Women's Imaging Nuclear Medicine PET. Sutter Imaging 29th Street t Sutter Imaging Alhambra t t t Sutter Imaging Amador t t t t t t t Sutter Imaging Auburn t t t t t t t Sutter Imaging Auburn Faith t t t t t t t Sutter Imaging Campus Commons t t t . Sutter Imaging Capitol Pavilion t t t t t t t Sutter Imaging Carmichael t t t t t t t t Sutter Imaging Davis t t t t t t Sutter Imaging Elk Grove t t t t t Sutter Imaging Fair eld t t t t t t t t Sutter Imaging Folsom I t t t t Sutter Imaging Folsom II t t t Sutter Imaging Greenback t Sutter Imaging Lincoln t Sutter Imaging Rancho Cordova t Sutter Imaging Roseville II t t t t t t Sutter Imaging Roseville Parkway t t t t t t t Sutter Imaging Roseville PET t t.

7 Sutter Imaging Sacramento t t t t t t t t Sutter Imaging South t t t t t t Sutter Imaging Vacaville t t t Sutter Imaging Vallejo t t t Sutter Imaging Woodland t Sutter Imaging Yuba City t t t t t t t