X-RAY REQUEST FORM


In - Home X-Ray/Ultrasound/Doppler Studies/Echocardiograms
5000 Long Beach Road, Island Park, NY 11558
Tel: (516)432-3800  -  1(800)554-4229

1(888)X RAY NOW  - Fax: (516)897-3915

Special

Instructions

For Office Use Only

Facility: __________________________
Technician: __________________________
Rads/Views: __________________________
Time of Exam: __________________________
# of patients seen: __________________________
Date of Services:

__________________________

____________________________________________________________________________________

ALL INFORMATION MUST BE COMPLETED - PLEASE PRINT

  - Patient's Name: 
   

_____________________________________________________________________
 (Last)                                                             (First)                                         (M.I.)                                       

  - Date of Birth:

_____________________________________  Male/Female: ____________________

  - Medicare:

______________________________ Suffix: ______________ Medicaid: ___________

  - Other Ins.:

________________________________ Insurance #: ___________________________

  - Room #:

______________      Facility Where ______________________________________________

 

Patient Resides ______________________________________________

Guarantor's Name & Address:

____________________________________________________________

 

____________________________________________________________

PATIENT OR AUTHORIZED PERSON'S SIGNATURE:

______________________________________

I authorize the release of any medical information release
necessary to process this claim and request payment
of benefits, either to myself or the party who accepts assignment.

Date: ______________ Time: ______________


TO BE COMPLETED BY PHYSICIAN FOR MEDICARE BILLING PURPOSES

Patient's signs/symptoms and recent medical history (As documented in patient's medical records that necessities this X-Ray(s)

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

AREA OF BODY TO BE X-RAYED
1. __________________ R/O __________________ 3. __________________ R/O __________________
2. __________________ R/O __________________ 4. __________________ R/O __________________

I certify that this X-Ray is medically necessary (Provide Doctor's Name):

_________________________________

Physician's Signature:

_____________________________________________ Date: ________________

Medicaid ID #:

_____________________________ Medicare UPIN #: ____________________________

NOTICE TO OFFICIALS: A Portable X-Ray is necessary because this patient is non-ambulatory and/or infirmed. Additionally, because of
advanced age and physical limitations, this patient would find it physically and/or psychologically taxing to receive X-Rays outside his or her
residence. THE PATIENT WILL BE RESPONSIBLE FOR ANY SERVICES NOT REIMBURSABLE BY THEIR INSURANCE.
ASSIGNMENT ACCEPTED: (Circle One)  YES / NO