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PROVIDER PORTAL

REFERRAL FORM

Use this form to send referrals directly to our team.

Patient's Name

Date of Birth

Patient Phone

Address

Room #

Primary Insurance

Secondary Insurance

Referring Physician

NPI #

Provider email

Name of Individual Completing Form

Provider Office Phone

Physician Signature

Instructions/Clinical History

Portable Service

STAT

ROUTINE

CD

FAX

PORTAL

You must select at least one exam from the list below.

DIGITAL X-RAY

Skull

Sinuses

Chest

Ribs R

Ribs L

Abdomen

KUB

Pelvis

C-Spine

T-Spine

L-Spine

Shoulder R

Shoulder L

Humerus R

Humerus L

Forearm R

Forearm L

Elbow R

Elbow L

Hand R

Hand L

Wrist R

Wrist L

Fingers R

Fingers L

Hips R

Hips L

Femur R

Femur L

Knee R

Tibia/Fibula R

Tibian/Fibula R

Tibia/Fibula L

Foot R

Foot L

Ankle R

Ankle L

Calcaneus R

Calcaneus L

Toes R

Toes L

OTHER SERVICES

Abdomen/Complete Ultrasound

Abdomen Spec. Attn Pelvic US

Renal Ultrasound

Renal/Bladder Ultrasound

Pelvis/Bladder Ultrasound

Female Pelvis (TA) Ultrasound

Male Pelvic (Prostate) Ultrasound

Scrotum/Testes Ultrasound

Arterial Doppler

Arterial Doppler Lower Extremity R

Arterial Doppler Lower Extremity L

Arterial Doppler Lower Extremity BIL

Arterial Doppler Upper Extremity R

Arterial Doppler Upper Extremity L

Arterial Doppler Upper Extremity BIL

Thyroid Ultrasound

Aorta Ultrasound

Breast Ultrasound

Echocardiogram

Echocardiogram Limited

EKG

Pacemaker

Carotid Doppler

Transcranial Doppler

Venous Doppler (DVT)

Venous Doppler Lower Extremity R

Venous Doppler Lower Extremity L

Venous Doppler Lower Extremity BIL

Venous Doppler Upper Extremity R

Venous Doppler Upper Extremity L

Venous Doppler Upper Extremity BIL

Other Study

DIAGNOSTIC CODES

171.4 Abnormal electrocardiogram

E11.9 Hypertensive heart disease, unspecified

I08.0 Valve insufficiency

N63 Lump/mass on breast

Z95.0 Cardiac Pace Maker

N39.0 Urinary tract infection

R42 Dizziness & giddiness

R21.3 Acute Myocardial Infarction unspecified site

I77.9 Unspecified of arteries and arterioles

I73.9 Peripheral vascular disease, unspecified

R60.9 Edema

Z07.9 Chest pain

R53.83 Other, fatigue

R00.2 Palpitations

R06.02 Shortness of breath

E66.01 Morbid Obesity

I82.409 DVT

171.4 Abdominal Aneurysm without mention of rupture

R10.84 Abdominal pain

Other DX code:

NOTE TO OFFICIALS: A portable service is being ordered since this patient would find it physically and/or psychologically taxing, because of advanced age and/or physical limitations to receive service outside the home. This test is medically necessary for the diagnosis and treatment of this patient.

ULTRASOUND PREP:
Abdomen - Nothing to eat or drink 4-6 hours prior to the exam.
Bladder - Drink 32oz of water 1 hour prior to the exam.
Renal Arterial Doppler - Nothing to eat or drink 2 hours prior to the exam.

Thanks for your referral!

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Suffolk (631) 551-5101

Nassau (516) 490-9058

NYC (345) 773-3464

90 Arrival Avenue

Suite 105

Ronkonkoma, NY 11779

F. (516) 490-9058

Portable@MasImaging.com

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