Fillable Desert Radiology to OBTAIN AUTH (Desert Radiology)

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Desert Radiology to OBTAIN AUTH (Desert Radiology)

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FOR DIAGNOSTIC MAMMO ONLY!!
Mark locaon of concern
Mammography:
Mammo SCREENING or Mammo DIAGNOSTIC w/ US (as needed, per paent symptoms)
Mammo SCREENING w/follow-up DIAGNOSTIC w/ US (as needed)
Mammo DIAGNOSTIC w/ US (as needed)
Other Women's Imaging
Breast US ______________________________________________________________________ Bilateral Le Right
Breast MRI w/ & wo ____________________________________________________________________________________
Ultrasound Other (specify) ________________________________________________________________________________
Breast Biopsy STEREOTACTIC ______________________________________________________________________________
Breast Biopsy US Guided _________________________________________________________________________________
Breast Biopsy MRI ______________________________________________________________________________________
DEXA ____________________________________________________________________________ ADD Vertebral Height
X-RAY (walk-in basis only, No Appointments) ______________________________________________________________________
Paent Name____________________________________________________________________________ DOB_________________________
Ph___________________________________ Cell Ph ____________________________________ Work/Alt ____________________________
Primary Ins______________________________________________________________ Policy #______________________________________
Authorizaon #______________________________________________________________
History / Symptoms (required)______________________________________________________________________________________________
ICD-10 / Diagnosis ____________________________________________________________________________________________________
Referring Physician __________________________________________________________________________________________________
Ph ___________________________ Fx ___________________________ CC Physician ___________________________________________
Oce Contact __________________________________________ CALL REPORT_________________________
CD to Oce CD w/ Paent DICOM CD to Oce Other __________________________________
Your appointment is scheduled / Su cita está previsto:
Date/Fecha: ___________________________Time/Hora: ___________________________
Arrival Time/Hora de llegada
:____________________________________________
DATE OF ORDER:
Desert Radiology to OBTAIN AUTH
03.10.2021
ICD 10 CODE / DIAGNOSIS:
Z12.31 Screening Mammogram
N60.19 Breast cyst
N64.4 Breast tenderness / pain
N63 Lump or mass in breast
C50.919 Breast Cancer
N64.51 Breast redness
N64.52 Nipple discharge
N64.53 Inversion of nipple
R92.0 Calcs/Micro calcicaons
R92.8 Addional imaging of breast
R92.0 Breast follow up
Z80.3 Family history breast cancer
Z85.3
Personal history breast cancer
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Desert Radiology to OBTAIN AUTH (Desert Radiology)

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Completed 7 April 2022

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