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Facility Order Request

 

Patient Information:

 

 Male Female

 

 Attach Face Sheet (optional)

 

Patient Insurance Information

 

Medicare Number:

Medicaid Number:

 

Other Insurance Provider:

Policy Number:

 

 

 

Type of Exam:

Please selectX-RayEKGUltrasoundPacemaker CheckHolter Monitor

X

Please selectX-RayEKGUltrasoundPacemaker CheckHolter Monitor

X

Please selectX-RayEKGUltrasoundPacemaker CheckHolter Monitor

X

Please selectX-RayEKGUltrasoundPacemaker CheckHolter Monitor

X

Please selectX-RayEKGUltrasoundPacemaker CheckHolter Monitor

X

 Order another exam?

 

Symptoms (the more the better):

Upload Script:

- or -

 I will fax script or requisition

“NOTE: Exam will not be finalized until fax is received”

 

(optional, for confirmation only)

 

Comments:

 

Completed

Refused / NA

Nurse Signature:

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Tech Signature:

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