66442 Physician Rx Pad - Gateway Diagnostic Imaging · 2015. 6. 11. · Prior to your appointment,...
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DIAGNOSIS/SYMPTOMS APPOINTMENT INFO DELIVERY INFO GDI TECH INITIALS GDI FD INITIALS FILMS REQUESTED Y______ N______ CD REQUESTED Y______ N______ PATIENT DELIVER______ COURIER______ MRI (1.5T) ____________________________________ (INCLUDING ARTHROGRAMS) MRA _________________________________________ OPEN MRI ____________________________________ (FORT WORTH) CT ___________________________________________ (INCLUDING MYELOGRAMS) CTA __________________________________________ ULTRASOUND GENERAL X-RAY ❑ PLEASE CALL AND SCHEDULE PATIENT ❑ PATIENT HAS ALREADY BEEN SCHEDULED DATE _____/_____/_____ TIME ______:______ ❑ a.m. ❑ p.m. RAD _____ W&W/O_____ W_____ W/O_____ TO DETERMINE RAD _____ W&W/O_____ W_____ W/O_____ TO DETERMINE RAD _____ W&W/O_____ W_____ W/O_____ TO DETERMINE RAD _____ W&W/O_____ W_____ W/O_____ TO DETERMINE RAD _____ W&W/O_____ W_____ W/O_____ TO DETERMINE (INCLUDING DOPPLER EXAMS: VENOUS, ARTERIAL, CAROTID, AND RENAL) (INCLUDING IVPs W/OUT TOMOS) GENERAL INFO WWW.GATEWAYDIAGNOSTIC.COM ❑ WEATHERFORD Phone (817) 599-8995 Fax (817) 599-6795 ❑ FT. WORTH MEDICAL DISTRICT Phone (817) 289-2002 Fax (817) 289-2010 ❑ MID CITIES / NORTH RICHLAND HILLS Phone 817-GATEWAY (428-3929) Fax (817) 428-1771 ❑ PLANO (Parker Rd. / Dallas N. Tollway) Phone (972) 378-3200 Fax (972) 378-3600 ❑ FRISCO (Warren Pkwy. / Dallas N. Tollway) Phone (214) 618-3100 Fax (214) 618-8508 GATEWAY D I IAGNOSTIC MAGING BECAUSE PATIENTS DESERVE MORE FOR LE$$ PATIENT NAME: ____________________________________ D.O.B.: _____/_____/_____ AGE: _________SEX: ________ PHONE (HOME): ____________________________________ (CELL): __________________________________________ *INS. NAME: ________________________________________ INS. ID#: __________________ GROUP #: _____________ *INS. AUTH.: _________________________________ GATEWAY OBTAIN AUTH: PHY TAX ID#: _________________________ (ONLY IF BOX CHECKED) PHYSICIAN INFORMATION - PLEASE SIGN BELOW REFERRING PHYSICIAN NAME:_______________________________ SIGNATURE:______________________________ REFERRAL COORDINATOR: ___________________ PHONE #: ______________________FAX#:____________________ MRI/CT PATIENTS NEEDS TRANSPORTATION (NON-CMS ONLY) * WE ALWAYS HONOR IN-NETWORK BENEFITS ■ STAT CALL■ ■ STAT FAX #
Transcript of 66442 Physician Rx Pad - Gateway Diagnostic Imaging · 2015. 6. 11. · Prior to your appointment,...
DIAGNOSIS/SYMPTOMS
APPOINTMENT INFO DELIVERY INFO
GDI TECH INITIALSGDI FD INITIALS
FILMS REQUESTED Y______ N______
CD REQUESTED Y______ N______
PATIENT DELIVER______ COURIER______
MRI (1.5T) ____________________________________ (INCLUDING ARTHROGRAMS)
MRA _________________________________________
OPEN MRI ____________________________________ (FORT WORTH)
CT ___________________________________________ (INCLUDING MYELOGRAMS)
CTA __________________________________________
ULTRASOUND
GENERAL X-RAY
❑ PLEASE CALL AND SCHEDULE PATIENT
❑ PATIENT HAS ALREADY BEEN SCHEDULED
DATE _____/_____/_____
TIME ______:______ ❑ a.m. ❑ p.m.
RAD _____ W&W/O_____ W_____ W/O_____TO DETERMINE
RAD _____ W&W/O_____ W_____ W/O_____TO DETERMINE
RAD _____ W&W/O_____ W_____ W/O_____TO DETERMINE
RAD _____ W&W/O_____ W_____ W/O_____TO DETERMINE
RAD _____ W&W/O_____ W_____ W/O_____TO DETERMINE
(INCLUDING DOPPLER EXAMS: VENOUS, ARTERIAL, CAROTID, AND RENAL)
(INCLUDING IVPs W/OUT TOMOS)
GENERAL INFO
WWW.GATEWAYDIAGNOSTIC.COM
❑ WEATHERFORDPhone (817) 599-8995Fax (817) 599-6795
❑ FT. WORTH MEDICAL DISTRICTPhone (817) 289-2002Fax (817) 289-2010
❑ MID CITIES / NORTH RICHLAND HILLSPhone 817-GATEWAY (428-3929)Fax (817) 428-1771
❑ PLANO (Parker Rd. / Dallas N. Tollway)Phone (972) 378-3200Fax (972) 378-3600
❑ FRISCO (Warren Pkwy. / Dallas N. Tollway)Phone (214) 618-3100 Fax (214) 618-8508
GATEWAYD IIAGNOSTIC MAGING
BECAUSE PATIENTS DESERVE MORE FOR LE$$
PATIENT NAME: ____________________________________ D.O.B.: _____/_____/_____ AGE: _________SEX: ________
PHONE (HOME): ____________________________________ (CELL): __________________________________________
*INS. NAME: ________________________________________ INS. ID#: __________________ GROUP #: _____________
*INS. AUTH.: _________________________________ GATEWAY OBTAIN AUTH: PHY TAX ID#: _________________________ (ONLY IF BOX CHECKED)
PHYSICIAN INFORMATION - PLEASE SIGN BELOW
REFERRING PHYSICIAN NAME:_______________________________ SIGNATURE:______________________________
REFERRAL COORDINATOR: ___________________ PHONE #: ______________________ FAX#:____________________
MRI/CT PATIENTS NEEDS TRANSPORTATION (NON-CMS ONLY)
* WE ALWAYS HONOR IN-NETWORK BENEFITS
■ STAT CALL ■■ STAT FAX #
Prior to your appointment, please inform the Gateway staff if you have prior medical imaging exams and/or previous surgery related to the area of your body of your currently scheduled exam. Bring all prior Films/CDs and reports to your exam.
MAGNETIC RESONANCE IMAGING (MRI)No preparation is necessary; however, please alert your MRI technologist if:• You have received a pacemaker, surgical clips, stents, prosthesis, or any other medical implants.• You have ANY metal objects in your body (metal fragments, bullet fragments, BBs, etc…)
COMPUTED TOMOGRAPHY (CT)Abdomen and Pelvis CT exams require specific test preparations. Please contact a Gateway staff member to receive preparation instructions.
ULTRASOUND (SONO)Most SONO exams require specific test preparations. Please contact a Gateway staff member to receive preparation instructions.
X-RAYNo preparation required.
EXAM PREPARATIONS
PLANO
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121
1106 Alston Avenue, Suite 175Ft. Worth, TX 76104Phone (817) 289-2002Fax (817) 289-2010➔ Located at S.E. corner of Rosedale andCollege in the same building as LabCorp
Grapevine Highway/Blvd. 26
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Mid Cities Blvd.9155 Grapevine Highway, Suite 210North Richland Hills, TX 76180Phone 817-GATEWAY (428-3929)Fax (817) 428-1771➔ Located @ N.W. corner of Precinct Line& Hwy 26 in Kohl’s shopping centerbehind First Choice ER
MID CITIES / NORTH RICHLAND HILLS
W. Parker Rd.
Wedgewood Dr.
Comm
unications Pkwy.
Da
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THRPresbyPlano
161
121 3060 Communications Parkway, Suite 103Plano, TX 75093Phone (972) 378-3200Fax (972) 378-3600
➔ Located S.W. of Parker and DNTjust south of THR Presby Plano
Eureka
WeatherfordHospital
Main
St. Ja
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Santa Fe Dr.
Santa Fe Dr.
20
H
51
180
20
831 Eureka StreetWeatherford, TX 76086Phone (817)599-8995Fax (817) 599-6795
➔ Located @ N.E. corner of Eureka & Santa Fe Dr.;east of Weatherford Hospital; use I-20 exit 409
WEATHERFORD
FT. WORTH MEDICAL DISTRICT
FRISCO
3550 Parkwood Blvd., Suite C-302Frisco, TX 75034Phone: (214) 618-3100Fax: (214) 618-8508➔ Located @ N.E. corner of Warren Pkwy. and Parkwood Blvd. in the Shantara Plaza office park; adjacent to the Holiday Inn Express
ModalitiesMRI 1.5TOpen MRICTU/SX-Ray
ModalitiesMRI 1.5TCTU/SX-Ray
Modalities MRI 1.5TCTU/SX-Ray
ModalitiesMRI 1.5TCTU/SX-Ray
ModalitiesMRI 1.5TCTU/SX-Ray121
161
380
Warren Pkwy
BaylorFrisco
CentennialMedicalCenter
Legacy Dr.
Parkwood Blvd.
Dallas N. Tollway
Preston
Coit
DNT
Preston Rd.
