Patient’s Name: Referring Physician: Todays Date1127 Wilshire Blvd. #100 Los Angeles, CA 90017...

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Transcript of Patient’s Name: Referring Physician: Todays Date1127 Wilshire Blvd. #100 Los Angeles, CA 90017...

Hip Bilat. 2V 3-4V+ Comp.

L R

L R

L R

L R

L R

L R

L R

L R

L R

L R

Hip Unilat. 1V 2V+ Comp.Hip Unilat. w/Pelvis 1V 2V+ Comp.

Femur 1V 2V + Comp.Knee 1-2V 3V 4V+ Comp.Knee Bilat.Tibia/Fibia 2VAnkle 2V 3V+ Comp.Foot 2V 3V+ Comp.Calcaneus 2V+ Comp.Toes 2V+ Comp.

L R

L R

L R

L R

L R

L R

L R

L R

L R

Scapula CompleteClavicle CompleteShoulder 1V 2V+ Comp.Elbow 2V 3V+ Comp.Humerus 2V+Forearm 2VWrist 2V 3V+ Comp.Hand 2V 3V+ Comp. Fingers 2V+ Comp.

Mandible 3V 4V+ Comp.Facial Bones 2V 3V+ Comp.Nasal Bone Complete – 3 ViewsOrbit Complete – 4 ViewsSinus 2V 3V+ Comp.Skull 3V 4V+ Comp.Neck Soft TissueC-Spine 2-3 4V+ Comp.T-Spine 2V 3V 4V+ Comp.L-Spine 2-3V 4V+ Comp.

Sacrum/Coccyx – 2 ViewsSacrum/Iliac – 3 ViewsScoliosis Supine/Erect – 4 Views

Unilateral Diagnostic - SpotCompressionBilateral DiagnosticAnnual Routine Screening

MAMMOGRAPHY

HEAD & SPINE CHEST, ABDOMEN & PELVIS UPPER EXTREMITIES

Unilat.

Unilat.

Unilat.

Bilat.

Bilat.

Bilat.

VASCULAR STUDIES

Full Body ScreeningCardiac Scoring

FULL BODY SCAN

Bone ScanLiver / SpleenLung Scan Perfusion & VentilationThyroid ScanParathyroid ScanThallium Rest & Stress / SpectOther

*NUCLEAR MEDICINE *

Brain / Refractory SeizureFull Body Skull Base to Mid-ThighWhole BodyMyocardial ViabilityOther

* PET SCANS *

Hip Bilat. w/Pelvis 2V 3-4V+ Comp.

LOWER EXTREMITIESX-RAY

Esophogram “Barium Swallow”UGISmall BowelBarium Enema

IVP LimitedCystographyVoiding cystogramHysterosalpingogram

IVP With TomosTomogram

With Air

FLUOROSCOPY AND IVP’S

CT SCANSMRI SCANS

MRA SCANS

TMJ

SPECIALTY MRI & MRA

ULTRASOUNDB.U.N. and Creatinine Lab Work RequiredFor all CT Contrast Studies

With 3-D Views

Without ContrastWith ContrastWith & WithoutContrast

With 3-D Views

Without ContrastWith ContrastWith & WithoutContrast

ArthrogramBrainOrbit Face/NeckC-SpineT-SpineL-SpineThoraxAbdomenPelvisUpper Extrem.

Upper Extrem. Joint

Lower Extrem.

Lower Extrem. Joint

BrainOrbits / Inner Auditory CanalSinusMaxillofacialDental[ ] Mandible [ ] MaxillaSoft Tissue NeckC-SpineT-SpineL-SpineThoraxAbdomenPelvisUrogramBone Mineral DensityOther

Duplex Lower ArterDuplex Upper ArterDuplex Extremity VeinDuplex Aorta Inf. Ven CavaCarotid Doppler - Head and NeckEchocardiogramPenile Vascular Evaluation

Chest 2 View Frontal & LateralRibs Unilateral 2V 3V+ Comp. L R

Ribs Bilateral 3V 4V+ Comp.Sternum 2V+Abdomen KUB 1 AP ViewAbdomen AP/Oblique/ConeKUB 3V+ Comp.Abdomen 1V 2V 3V+Pelvis 1-2V 3V+ Comp.

BrainNeckChest

AbdomenPelvisSpine

Breast MRI W/Axillary GlandsMRCPMRI Brain - Functional SensoryCardiac MorphologyOther

Neck/Soft TissueThyroidBreastAbdomen CompleteGallbladder/Biliary DuctRenalTesticularTransrectal - ProstatePelvicTransvaginalOB Ultrasound - After 24 wks.

Other

www.umih.com

UMI TAX ID # 20-5386244

STATPREP REQUIREDExam is TECH ONLYFax Report to O

CONSULTATION REPORTS

Address:

Referring Physician: Todays Date:

Reason For Exam/Signs & Symptoms/Clinical History (Required*)

Attorney’s Name: Attorney’s Phone:

Signature: Physician Phone: Fax:

Name of Authorization IPA: :ecnarusnIfoepyT

Medi-Cal Medicare Medi-Medi HMO Private Insurance PI WC BD BP Cash

Date of Birth: Appointment Date: Time:

Patient’s Name: Patient’s Phone:

*Medicare & other insurers require coding of specific/definitive diagnosis(es), sign(s) or symptom(s) to reflect the medical necessity for each test. Rule out, possible, or probable conditions cannot be coded

*ICD-10:

Send CD with PatientMail CD to O�ce w/Report

UMI OF EAST LONG BEACH: 2600 Redondo Ave. #101, Long Beach, CA 90806 Tel: (562) 424-4100 | Fax: (562) 264-3442

UMI OF INGLEWOOD: 110 South La Brea #150, Inglewood, CA 90301 Tel: (310) 671-6000 | Fax: (310) 671-6302UMI OF GARDENA 1141 W. Redondo Beach.,#105, Gardena, CA 90247 Tel: (310) 818-2000 | Fax: (310) 436-1731

UMI OF TORRANCE 3640 Lomita Blvd., #105, Torrance, CA 90505 Tel: (310) 802-7000 | Fax: (310) 375-8659

UMI OF CENTRAL LONG BEACH: 701 E. 28th St. #318, Long Beach, CA 90806 Tel: (562) 426-7000 | Fax: (562) 426-7099

UMI OF SOUTH LONG BEACH: 1040 Elm Ave. #102, Long Beach, CA 90813 Tel: (562) 285-1000 | Fax: (562) 285-1019

NEW

Chest 1V 2V 3V 4V+

Myelogram AreaDexa Bone Density

BreastThyroidLymphnode

SPECIAL PROCEDURES

* U/S GUIDED BIOPSY *

* STEREOTACTIC BIOPSY **AVAILABLE AT: FOUNTAIN VALLEY & WEST COVINA

Breast

*AVAILABLE AT: DOWNEY, GLENDALE, HUNTINGTON BEACH, LOS ANGELES & WEST COVINA

24 Convenient Locations To Serve All Your Medical Imaging NeedsYou May Obtain Authorizations Using Our Parent Tax ID# 20-5386244

19. 20.17. 18.

11.

8.

9.

23.21. 22.16161 Gothard St. #C

Huntington Beach, CA 92647Tel: (714) 500-6600Fax: (714) 500-4099

UMI OF HUNTINGTON BEACH

11160 Warner Ave. #105Fountain Valley, CA 92708

Tel: (714) 619-7500Fax: (714) 619-7599

UMI OF FOUNTAIN VALLEY

10.

5. 6. 7.

3.624 S. Central Ave.Glendale, CA 91204Tel: (818) 241-3369Fax: (818) 485-2213

UMI OF GLENDALE1. 2.18250 Roscoe Blvd. #135

Northridge, CA 91325Tel: (818) 701-7111Fax: (818) 701-7841

UMI OF NORTHRIDGE

12.

L O S A N G E L E S C O U N T Y

O R A N G E C O U N T Y

6131 Orangethorpe Ave. #130Buena Park, CA 90620Tel: (714) 522-2077Fax: (714) 522-2474

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Tel: (714) 620-8200Fax: (714) 620-8211

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380 W Central Ave #210Brea. CA 92821

Tel: (714) 987-6000Fax: (714) 987-6019

UMI OF BREA

1801 W. Romneya Dr. #104Anaheim, CA 92801Tel: (714) 678-4000Fax: (714) 678-4022

UMI OF ANAHEIM

13.

24036 Lyons Ave. Newhall, CA 91321Tel: (661) 255-2111Fax: (661) 255-2812

UMI OF SANTA CLARITA

6310 San Vicente Blvd., #102Los Angeles, CA 90048

Tel: (323) 556-3000Fax: (323) 556-3012

UMI OF MID-WILSHIRE

3513 Whittier Blvd.Los Angeles, CA 90023

Tel: (323) 859-8000Fax: (323) 262-1699

UMI OF EAST LOS ANGELES

110 South La Brea #150Inglewood, CA 90301Tel: (310) 671-6000Fax: (310) 671-6302

UMI OF INGLEWOOD

1127 Wilshire Blvd. #100Los Angeles, CA 90017

Tel: (213) 223-5000Fax: (213) 202-5709

UMI OF LOS ANGELES

1141 W. Redondo Beach #105Gardena, CA 90247Tel: (310) 818-2000Fax: (310) 436-1731

UMI OF GARDENA

11411 Brookshire Ave. #101Downey, CA 90241Tel: (562) 869-9192Fax: (562) 250-1423

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4316 E. Slauson Ave.Maywood, CA 90270Tel: (323) 374-6200Fax: (323) 771-6094

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3640 Lomita Blvd. #105Torrance, CA 90505Tel: (310) 802-7000Fax: (310) 375-8659

UMI OF TORRANCE

701 E. 28th St. #318Long Beach, CA 90806

Tel: (562) 426-7000Fax: (562) 426-7099

UMI OF CENTRAL LONG BEACH 14. 16.15.1040 Elm Ave. #102

Long Beach, CA 90813Tel: (562) 285-1000Fax: (562) 285-1019

UMI OF SOUTH LONG BEACH

1401 W. Merced Ave., #102West Covina, CA 91790

Tel: (626) 813-6100Fax: (626) 813-0075

UMI OF WEST COVINA

2600 Redondo Ave. #101 Long Beach, CA 90806

Tel: (562) 424-4100 Fax: (562) 264-3442

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24.800 N Tustin Ave Ste M

Santa Ana, CA 92705Tel: (714) 450-1410Fax: (714) 450-1429

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15825 Laguna Canyon Rd. #101Irvine, CA 92618

Tel: (949) 777-9000Fax: (949) 777-9007

UMI OF IRVINE

4.2080 Century Park East #104

Los Angeles, CA. 90067Tel: (310) 432-8000Fax: (310) 432-8019

UMI OF CENTURY CITY