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___________ ARKANSAS MEDICAID EXTENSION OF BENEFITS Today’s Date RADIOLOGY REFERRAL FORM__________________________________________________________________________________________________Name of PatientD.O.B. Medicaid ID#____________________________________________________________________________________________________________Reason for Test (Please provide a brief description supporting the reason for ordering the requested testing)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Referring/Ordering Physician’s Name (Please PRINT)Referring/Ordering Physician’s Medicaid/NPI #____________________________________________________________________________________________________________Referring/Ordering Physician’s SignatureDate of Signature____________________________________________________________________________________________________________Primary Care Physician’s Name (Please PRINT) PCP Medicaid/NPI #RADIOGRAPHIC EXAMS□ Specify # of views ______________□ Head/neck (specify)________________________________□ Chest □ Ribs □ Abdominal (specify)________________________□ Spine □ Cervical □ Thoracic □ Lumbar □ Pelvic□ Joint _________________________ □ RT □ LT □Bilateral□ Other ________________________RADIOGRAPHIC SPECIAL EXAMS□ Vascular (specify)_________________________________□ Gastrointestinal (specify)___________________________□ Urinary (specify)__________________________________□ Arthrogram (specify joint) __________________________□ Bone Density/Osteoporosis StudyULTRASOUND EXAMS□ Head/Neck □ Ophthalmic □ Chest □ Heart □ Aorta □ Abdomen □ Gall Bladder □ Retroperitoneal □ Trans-rectal □ Scrotum□ Non-OB Gynecological (specify)______________________ □ Extremity (specify)_________________________________ □ Other ___________________________________________VASCULAR ULTRASOUND□ Carotid Doppler□ Arterial Doppler □ Upper □Lower□ Venous Doppler □Upper □Lower □RT □LT □BilateralCT SCAN (Computed Tomography)□ with contrast □ without contrast□ Brain □ Sinus □ Soft tissue neck □ Chest□ Abdomen □ Pelvis □ Renal stone protocol□ Spine □Cervical □ Thoracic □ Lumber□ Joint/Extremity (specify) ___________________________ □ CT Angiography (specify)____________________________□ RT □ LT □Bilateral (if applicable)□ Other (specify)____________________________________MAMMOGRAPHY□RT □ LT □Bilateral□ Screening Mammogram□ Diagnostic Mammogram (requires diagnosis)/Ultrasound If necessary□ Breast Ultrasound□ Breast procedures (specify- e.g. core biopsy, aspirations, ductogram pre-op localization)_________________________OTHER□ Bone/Joint (specify)_______________________________□ PET (specify)_____________________________________ □ Other (specify) ____________________________________________________________________________________________________ ................
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