ORDER ONLINE FORM

Required fields are marked with an asterisk (*) and must be filled in.

PHYSICIAN/PRACTITIONER MEDICAL ORDER

Medical Record of Portable X-Ray Services - A copy of this record must be retained as part of the patient medical records.

Medicare requires that the medical records (nurse’s notes & physician notes) corroborate with this order.

Date of Order:

Ordering Physician/Practitioner:

Referring Account:

Phone #:

Fax #:

Patient Name:

DOB:

POC Phone #:

Secondary Phone#:

Patient Social Security #:

Patient/Facility Address:

RM#:

City:

State:

Zip:

Gender

Male

Female

Primary Insurance:

Policy Number:

Group Number:

Secondary Insurance:

Policy Number:

Group Number:

Type of X-RAY Exam(s) (Area of Body to be Exposed)	# Radiographs/Views

Symptoms/Reasons for X-ray(s)

STAT

Routine

Special Instructions

Ultrasound/Doppler: Type of Exam:

Symptom/Reason for Exam

Please provide a statement below explaining the reason WHY THIS PATIENT NEEDS THIS X-RAY AT THEIR place of residence INSTEAD OF AN OUTSIDE FACILITY. This patient needs a “PORTABLE” x-ray instead of being transported to an outside facility due to the following:

Physician/Practitioner Signature:

Please sign below:

NPI#

Person Submitting Order

Phone #

Medical Record Attestation Acknowledgement I understand that the medical record for the date of service on this order is accurately documented and notated by the ordering provider at the time of treatment. The information in this document is true and complete to the best of my knowledge. Per federal regulations 42 CFR §486.106 and §410.32 I acknowledge that I am in compliance with medical records pertaining to ordering portable x-rays.

Physician/Practitioner Signature:

Please sign below:

Communication Note for Portable X-Ray Supporting Medical Necessity

Patient Name

Order Date

Physician/Provider

Reason for Exam

Please provide explanation for ordering exam (e.g., patient fell and complaining of right hip pain, ordering portable x-ray of right hip to r/o fracture).

Signature

Please sign below:

Communication Note for Portable X-Ray Supporting Medical Necessity Signature Patient Name Order Date Physician/Provider Reason for Exam Medical Record Attestation Acknowledgement I understand that the medical record for the date of service on this order is accurately documented and notated by the ordering provider at the time of treatment. The information in this document is true and complete to the best of my knowledge. Per federal regulations 42 CFR §486.106 and §410.32 I acknowledge that I am in compliance with medical records pertaining to ordering portable x-rays.