Washington University in St. Louis



Request for St. Louis Children’s Hospital Radiology Testing Availability

To request testing availability for Radiology research tests, please fill in all applicable fields.

Availability is based on CPT codes provided below and reflect the routine time and activities required when that clinical CPT code is billed.

Pricing is provided by St. Louis Children’s Hospital Finance Department – Please complete the form labeled Pricing Request for St. Louis Children’s Hospital Clinical Study on the CCS Website. Pricing is based on the CPT code, please note if the patient will require sedation.

Date of Request: PI Name:

Requester Name: PI Email:

Requester Email: Requester Phone:

IRB #: Protocol ID #:

Sedation necessary: Professional Reading Required:

(note: all images will be available in Clinical Desktop)

Radiology:

|Procedure * (Nuc Med, US, IR and MRI |CPT Code(s) |MRI Scanner Required Location |

|require approval) | |MRI 1, MRI 2, MRI 3 |

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* For Radiology protocols outside the normal scope of the CPT Code, please check the Radiology area and submit with the Imaging Acquisition Guidelines (IAG) to contacts below.

☐ MRI: ☐ CT: ☐ US:

Dan Huellewig Anne Klepner Stacey Reime

daniel.huellewig@ anne.klepner@ stacey.reime@

☐ Nuclear Medicine: ☐ Interventional Radiology: ☐ General Radiography

Kristine Hellige Anne Klepner Anne Klepner

kristine.hellige@ anne.klepner@ anne.klepner@

☐ SLCH Radiology Manager ☐ WUMC Professional Services:

Crystal Crosby Darci R. Denner, PhD

crystal.crosby@ 314-362-6213

Campus Box # 8131

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