Fillable CT Upper and Lower Extremity Imaging Request (eviCore)

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CT Upper and Lower Extremity Imaging Request (eviCore)

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The CT Upper and Lower Extremity Imaging Request (eviCore) form is 2 pages long and contains:

  • 0 signatures
  • 8 check-boxes
  • 110 other fields

Country of origin: US
File type: PDF

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First Name:
Middle Initial: Last Name:
DOB (mm/dd/yyyy ):
Gender: Male Female
Street Address: Apt #:
City: State: Zip:
Cell Phone:
Primary Contact:
Home Cell
Health Plan: Member ID: Group ID:
First Name: Last Name:
Primary Specialty:
TIN: NPI:
Physician Phone: Physician Fax:
Address: Suite #:
City: State: Zip:
Office Contact: Ext:
Contact Email:
First Name: Last Name:
Group/Site Name:
Primary Specialty:
TIN: NPI:
Site Phone: Site Fax:
Address: Suite #:
City: State: Zip:
CT UPPER EXT: 73200 73201 73202
CT LOWER EXT: 73700 73701 73702
Other:
Diagnosis, if known or rule out:
ICD-10 Codes:
Date of last visit:
Page 1 of 2
Facility/Site
Patient/Member
Home Phone:
Ordering Provider
Procedure
Check all
applicable
CPT Codes:
Diagnosis
CONFIDENTIALITY NOTICE: This fax transmission, and any documents attached to it may contain confidential or privileged information subject to privacy
regulations such as the Health Insurance Portability and Accountability Act of 1996 (HIPAA). 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 any
disclosure, copying, distribution or use of any of the information contained in or attached to this transmission is STRICTLY PROHIBITED. If you have
received this transmission in error, please immediately notify eviCore healthcare and destroy the original transmission and its attachments without saving
them in any manner.
CT Upper and Lower Extremity Imaging Request
For NON-URGENT requests, please fax this completed document along with medical records, imaging, tests, etc.
If there are any inconsistencies with the medical office records, please elaborate in the comment VHFWLRQ)DLOXUHWR
provide all relevant information may delay the determination.
request. authorization an submit
to site the on located portal provider the into log also may You section. Forms Fax and Guidelines the under
eviCore.com on found be can numbers fax and Phone
URGENT (same day) REQUESTS MUST BE SUBMITTED BY PHONE.
eviCore healthcare | www.eviCore.com | 400 Buckwalter Place Blvd • Bluffton, SC • 29910 | 800.918.8924
1. Date of most recent office visit or other contact with physician: Don't Know
Phone call with office staff
Phone call with physician
Don't Know
Other:
3. What was the date for the FIRST office visit for this episode of symptoms (should pain, knee pain, etc.)?
Date:
This is the first visit for this episode
Don't Know
4. Has a specialist evaluation been completed? Yes No Don't Know
5. Has there been a recent injury? Yes No Don't Know
6. Has an X-ray been done? Yes No Don't Know
Yes No Don't Know
8. Is this study to evaluate arthritis? Yes No Don't Know
9. What is the range of motion? Limited/Painful Don’t Know
10. Has there been a period of conservative treatment?
3 weeks or less 8 or more weeks
4 weeks No Treatment
6 weeks Don't Know
11. Indicate type of physician directed treatment (select all that apply):
Splinting/Bracing
Steroid injections
Other:
No Treatment
Don't Know
Additonal Information/Comments:
Who is making this request? Ordering Physician Facility Other:
Print Name:
Title: MD RN LPN PA NP Other:
Signature: Date:
Page 2 of 2
Clinical Information
2. Type of most recent documented contact with physician?
Hospital
Office visit
Email
Submitter
7. Is there a personal history of cancer other than ordinary skin cancer?
Full Motion
N-S-A-I-D-S (Nonsteroidal anti-inflammatory
drugs) and/or oral steroids
eviCore healthcare | www.eviCore.com | 400 Buckwalter Place Blvd • Bluffton, SC • 29910 | 800.918.8924
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CT Upper and Lower Extremity Imaging Request (eviCore)

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Completed 19 November 2021

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