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 | University of North Carolina Health Care System Radiology Imaging Order Form
 | MIM#:________________, Clinic Code:_____________
 | Ordering Provider Name:_________________________Ordering Provider#:_______________
 | Provider Pager:__________Clinic Contact:____________________Pager/tel no.:___________
 | Date of service: ________________________Time of service:___________________
 |  |  |  |  |  |  |  |  | [NAME]
 | Procedure | Body Part |  |  |  |  | CPT Code | Contrast
 |  |  |  |  |  |  |  | With | Without | With and Without
 | CT
 | CTA
 | MRI
 | MRA
 | PET
 | Nuclear Cardiology
 | *Please provide the most revelant signs and/or symptoms (see back for detailed description required for Notification/Authorization Request) ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
 | REQUIRED Questions for Commercial Insurance Carriers
 | 1. List all previous diagnostic studies completed related to this symptom/event:_____________________________________
 |  |  | (e.g. ultrasound, x-ray)
 | 2. List all previous treatments completed related to this sympton/event:____________________________________________
 |  |  | (e.g. NSAIDS, antibiotics)
 | 3. List all risk factors associated with this symptom/event:________________________________________________________
 |  |  | (e.g. age, chemotherapy)
 | 4. List all complicating factors associated with this symptom/event________________________________________________
 |  |  | (e.g. Cancer, Immunocompromised)
 | Department of Radiology required CT questions: |  |  |  | Department of Radiology required MRI questions
 | 1. Has the patient had an allergic reaction to IV contrast? |  |  |  | 1. Does the patient have a cardiac pacemaker?
 |  | ___________Yes,      __________No |  |  |  | __________Yes,     ________No
 | 2. Is he pt on Glucophage (melformin)? |  |  |  | 2. Does the patient have an aneurysm clip?
 |  | ___________Yes,      _________No |  |  |  | __________Yes,    _________No
 | 3. History of Diabetes, mulitple myeloma, lubpus or scleroderma |  |  |  | 3. Does the patient have a cardiac heart valve?
 |  | ___________Yes,     _________No |  |  |  | __________Yes,    _________No
 | 4. Is pt on IV antibiotics or taking daily doses of |  |  |  | 4. Does the patient have any mechanical devises or implants
 |  | NSAIDs (Advil, Aleve, [NAME], [NAME])? |  |  |  | (neruostimulators, cochlear implants)?
 |  | __________Yes,   ___________No
 |  | If yes, a serum creatinine is required |  |  |  | __________Yes,    _________No
 | 5. Does pt have recent(within 6 mos) [NAME]? |  |  |  | 5. Is the pt claustrophobic?
 |  | __________Yes,     _________ No |  |  |  | __________Yes,     ________No
 |  | If yes, VALUE____________, DATE, ___________ |  |  |  | Is sedation needed?
 |  | If, NO the test needs to be drawn BEFORE the study |  |  |  | __________Yes,     ________No
 |  | The result can be called in or the pt can bring results
 |  | on the date of the study.
 | 6. Does the pt have previous studies NOT done at UNC?
 |  | ___________Yes,    _________No
 |  | If yes remind pt to bring studies for comparison
 |  |  |  |  |  |  | Notification/Authorization Number:
 | Ordering Physician Signature: I certify that these diagnosis codes support the test ordered and are medically necessary
 |  |  |  |  |  | Non-elective
 | Date: |  |  |  |  | Elective: a reasonable delay in treatment will not adversely affect the outcome