TO vieW iMAges AND rePOrTs ONliNe, visiT Our WeBsiTe AT ...€¦ · TO vieW iMAges AND rePOrTs...
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RADIOLOGY ASSOCIATES OF PA ALBUQUERQUE REV 9/15 Albuquerque Imaging Center Office # 505-243-4401 Fax #505-243-6474 Offering MRI Services 700 Lomas NE, 4 Woodward Center High Resolution Office # 505-332-5800 Fax #505-332-5801 Offering DEXA, Mammography, Mobile Mammography, (see back for locations), MRI and Ultrasound (breast and pelvic) 4411 The 25 Way NE, Suite 150 High Resolution RUST Office # 505-998-7719 Fax #505-998-7722 Offering Screening Mammography Only 2400 Unser Blvd. SE Rio Rancho, NM 87124 2nd floor of Physician Office Building, Suite #28200 RAA Imaging Office # 505-332-5800 Fax #505-332-5801 Offering Lung Cancer Screening, CT, Fluoroscopy, General Ultrasound, and X-Ray 4411 The 25 Way NE, Suite 150 LOW DOSE CT LUNG CANCER SCREENING ( PLEASE FILL OUT ALL AREAS) Screening Exam Follow Up Exam Patient is asymptomatic for lung cancer Yes No (If no, patient will need to be scheduled for Chest CT w/o contrast) Age (55-77) __________ Pack year history (Minimum of 30 packs years) _________ Current Smoker? Yes No (If no, how many years since patient has quit) _________ Referring Physician NPI Number__________________________ MRI/CT EXAMS MRI Exams: Is Patient Claustrophobic? Yes No If yes, be sure to inform our Scheduling department Patient Insurance __________________________ Policy or ID # _____________________________________________ Insurance Phone Number ________________________ Group # ____________________________________________ Needs Creatinine Test within 30 days of appointment date. Has Patient has a recent Creatinine? Yes No If yes, date _______ Prior Authorization Number if Required _________________________________________________________________ AIC and High Resolution may be found under AILLC (Advanced Imaging LLC) when calling to obtain a prior authorization. Exam Requested Exam Indication/ICD9 (For MRI and CT Fill Out Next Portion Below) 1. ________________________________________________ 1. _________________________________________________ 2. ________________________________________________ 2. _________________________________________________ 3. ________________________________________________ 3. _________________________________________________ Other Pertinent Information ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ Printed Physician Name: ______________________ Phone Number: ______________ Fax Number: ______________ Physician Signature: ____________________________________ Date: ___________________________________ (Must be physician signature; we no longer accept a stamped signature) Send copy of results to: __________________________________________________________________________ Send a Copy of Exam with Patient Send Copy of Exam to Ordering Physician STAT READING Yes No Call Results Attn: ____________________________ Phone #: ______________________ Appointment Date ________________ Appointment Time _________________ AM / PM (Arrive 15 Minutes Early To Register) Patient Name _____________________________ DOB ________________ Female Male Height _______ Weight ________ Home # ___________________________ Cell # ___________________________ Work # ___________________________ Please do not bring children needing supervision to your exam.
Transcript of TO vieW iMAges AND rePOrTs ONliNe, visiT Our WeBsiTe AT ...€¦ · TO vieW iMAges AND rePOrTs...
12922RAA-GenericFormREV-1.pdf 1 12/3/12 11:53 AMR A D I O L O G Y A S S O C I A T E S
O F P AA L B U Q U E R Q U E
R A D I O L O G Y A S S O C I A T E S
O F P AA L B U Q U E R Q U E
Centralized Scheduling Phone505-332-6967
Or Toll Free 1-877-771-6266
Centralized Scheduling fax505-332-5890
Albuquerque Imaging CenterOffice # 505-243-4401Fax #505-243-6474Offering MR Services
High ResolutionOffice # 505-332-5800Fax # 505-332-5801Offering DEXA, Mammography, MobileMammography, (see back for locations),And Ultrasound (breast and pelvic)
RAA ImagingOffice # 505-332-5800Fax # 505-332-5801Offering CT, Fluoroscopy, General Ultrasound, and X-Ray
Appointment Date __________________ Appointment Time ___________________AM/PM (Arrive 15 Minutes Early To Register)
Patient Name _________________________________DOB ___________________ Female Male Height _________Weight ________
Home# _________________________________Cell # ________________________________ Work# ________________________________
Exam Requested Exam Indication/ICD9(For MRI and CT Fill Out Next Portion Below)
1. ________________________________________________ 1 _________________________________________________
2. ________________________________________________ 2. ________________________________________________
3. ________________________________________________ 3. ________________________________________________
Other Pertinent Information_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Please do not bring children needing supervision to your exam.
MRI/CT EXAMS MRI Exams: Is Patient Claustrophobic Yes No If yes, be sure to inform our scheduling department
Patient Insurance ________________________________ Policy or ID # ____________________________________________________
Insurance Phone Number ________________________________ Group# ___________________________________________________
Needs Creatinine Test within 30 days of appointment date. Has Patient had a recent Creatinine? Yes No If yes, date ___________
Prior Authorization Number if Required ______________________________________________________________________________
AIC and High Resolution may be found under AILLC (Advanced Imaging LLC) when calling to obtain a prior authorization.
Printed Physician Name: __________________________ Phone Number: _____________________Fax Number: _________________
Physician Signature _______________________________________ Date: __________________________________________________(Must be physician signature, we no longer accept a stamped signature)
Send copy of results to: _____________________________________________________________________________________________
Send a Copy of Exam with patient Send Copy of Exam to Ordering Physician
STAT READING YES NO Call Results Attn: _________________________Phone #: ___________________________________
TO vieW iMAges AND rePOrTs ONliNe, visiT Our WeBsiTe ATwww.RAAONLINE.COM, Or CAll (505) 332-6999
REV 9/15
Albuquerque Imaging Center Office # 505-243-4401 Fax #505-243-6474 O ffering MRI Services 700 Lomas NE, 4 Woodward Center
High Resolution Office # 505-332-5800 Fax #505-332-5801 Offering DEXA, Mammography, Mobile Mammography, (see back for locations), MRI and Ultrasound (breast and pelvic) 4411 The 25 Way NE, Suite 150
High Resolution RUST Office # 505-998-7719 Fax #505-998-7722 Offering Screening Mammography Only 2400 Unser Blvd. SE Rio Rancho, NM 87124 2nd floor of Physician Office Building, Suite #28200
RAA Imaging Office # 505-332-5800 Fax #505-332-5801 Offering Lung Cancer Screening, CT, Fluoroscopy, General Ultrasound, and X-Ray 4411 The 25 Way NE, Suite 150
LOW DOSE CT LUNG CANCER SCREENING ( PLEASE FILL OUT ALL AREAS)
Screening Exam Follow Up Exam
Patient is asymptomatic for lung cancer Yes No (If no, patient will need to be scheduled for Chest CT w/o contrast)
Age (55-77) __________ Pack year history (Minimum of 30 packs years) _________
Current Smoker? Yes No (If no, how many years since patient has quit) _________
Referring Physician NPI Number__________________________
MRI/CT EXAMS MRI Exams: Is Patient Claustrophobic? Yes No If yes, be sure to inform our Scheduling department
Patient Insurance __________________________ Policy or ID # _____________________________________________
Insurance Phone Number ________________________ Group # ____________________________________________
Needs Creatinine Test within 30 days of appointment date. Has Patient has a recent Creatinine? Yes No If yes, date _______
Prior Authorization Number if Required _________________________________________________________________
AIC and High Resolution may be found under AILLC (Advanced Imaging LLC) when calling to obtain a prior authorization.
Exam Requested Exam Indication/ICD9(For MRI and CT Fill Out Next Portion Below)
1. ________________________________________________ 1. _________________________________________________
2. ________________________________________________ 2. _________________________________________________
3. ________________________________________________ 3. _________________________________________________
Other Pertinent Information
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Printed Physician Name: ______________________ Phone Number: ______________ Fax Number: ______________
Physician Signature: ____________________________________ Date: ___________________________________(Must be physician signature; we no longer accept a stamped signature)
Send copy of results to: __________________________________________________________________________
Send a Copy of Exam with Patient Send Copy of Exam to Ordering Physician
STAT READING Yes No Call Results Attn: ____________________________ Phone #: ______________________
Appointment Date ________________ Appointment Time _________________ AM / PM (Arrive 15 Minutes Early To Register)
Patient Name _____________________________ DOB ________________ Female Male Height _______ Weight ________
Home # ___________________________ Cell # ___________________________ Work # ___________________________
Please do not bring children needing supervision to your exam.
R A D I O L O G Y A S S O C I A T E S
O F P AA L B U Q U E R Q U E
R A D I O L O G Y A S S O C I A T E S
O F P AA L B U Q U E R Q U E
Proudly owns and oPerates
albuquerque imaging centerHigh resolutionraa imaging
HigH resolution mammoVan – High resolution provides mobile mammography services in belen, rio rancho, and socorro at Presbyterian medical group clinics
1.Albuquerque Imaging Center 243-4401 4WoodwardCenter 700LomasNE Albuquerque,NM87102
ProvidesMRonly OpenMRatthislocation
2.High Resolution 332-5800 RAA Imaging 4411The25WayNE Suite150 Albuquerque,NM87109
3.Presbyterian Hospital 1100CentralSE,Albuquerque,NM87106CT,Fluoroscopy,IVP,NuclearMedicine, X-Ray,Color-Doppler,Neuro-Doppler, Neuro-Pediatric,GuidedBiopsy, SpectImaging,I-131Therapy, InterventionalandUltrasound
4.Presbyterian Kaseman Hospital 8300ConstitutionNE,Albuquerque,NM87110 CT,Fluoroscopy,IVP,NuclearMedicine, X-Ray,SpectImaging,I-131Therapyand Ultrasound
5.Presbyterian Rio Rancho Radiology 4100HighResortBoulevard,RioRancho,NM87124 OpenMR,X-Ray
6.Presbyterian Rust Medical Center 2400UnserBlvd.SE,RioRancho,NM87124 CT,Fluoroscopy,InterventionalRadiology,IVP, MR,NuclearMedicine,UltrasoundandX-Ray
The total cost of an X-ray is comprised of two fees: The Technical Fee covers the use of equipment, supplies and technical personnel. The Professional Fee is for reading the images or performing a procedure. Radiologists bill separately for their professional services.Please feel free to discuss your bill with us: 505-332-6900
Your appointment is scheduled at the location checked below:
2
3
Your appointment is scheduled at the location checked below:
1. Albuquerque Imaging Center 243-4401 4 Woodward Center 700 Lomas NE Albuquerque, NM 87102
2. High Resolution RAA Imaging 332-5800 4411 The 25 Way NE Suite 150 Albuquerque, NM 87109
3. Presbyterian Hospital 841-1181 1100 Central SE, Albuquerque, NM 87106
1
Lomas
Hig
h S
t.
Woodward Place
WoodwardCenter
MLK Elm
Locu
st
I-25
4Albuquerque
Imaging Center
1 23
HeartHospital
I-40
EmbassySuites
NORTH
NORTH
Jeff
ers
on
Fox andHound
Boston’s
PF Chang’s
Bank
The 25 Way
Entrance
Jefferson
Shops@25
SingerThe 25 Way
I-25
Fronta
ge Road
South
HIGHRESOLUTION
RAAIMAGINNG
CT, Fluoroscopy, IVP, Nuclear Medicine,X-Ray, Color-Doppler, Neuro-Doppler,Neuro-Pediatric, Guided Biopsy,Spect Imaging, I-131 Therapy,Interventional and Ultrasound
HIGH RESOLUTION
Provides MR onlyOpen MR at this location
BSGI, DEXA, Mammography, MR and Ultrasound (breast & pelvic)
CT, Fluoroscopy, General Ultrasound and X-Ray
CT, Fluoroscopy, IVP, Nuclear Medicine, X-Ray, Spect Imaging, I-131 Therapy andUltrasound
DEXA, CT, MR,X-Ray and Ultrasound
44. Presbyterian Kaseman Hospital 291-2462 8300 Constitution NE, Albuquerque, NM 87110
PresbyterianHospital
Central
Ced
ar
Silver
OakI-25
55. Presbyterian Rio Rancho Radiology 462-8815 4100 High Resort Boulevard, Rio Rancho, NM 87124
Constitution
I-40
Wyo
min
g
Constitution Place
Pen
nsyl
vani
a
PresbyterianKasemanHospital
PresbyterianRio RanchoRadiology
High Resort Blvd.
Rio
Ran
cho
Blvd
.
The total cost of an X-ray is comprised of two fees: the Technical Fee covers the use of equipment,supplies and technical personnel. The Professional Fee is for reading the images or performing a procedure.Radiologists bill separately for their professional services.Please feel free to discuss your bill with us: 505-332-6900
RAA IMAGING
RAA, PA p rov ides p ro fess iona l rad io logy ser v ices to the fo l low ing Presby te r ian loca t ions :
2
3
Your appointment is scheduled at the location checked below:
1. Albuquerque Imaging Center 243-4401 4 Woodward Center 700 Lomas NE Albuquerque, NM 87102
2. High Resolution RAA Imaging 332-5800 4411 The 25 Way NE Suite 150 Albuquerque, NM 87109
3. Presbyterian Hospital 841-1181 1100 Central SE, Albuquerque, NM 87106
1
Lomas
Hig
h S
t.
Woodward Place
WoodwardCenter
MLK Elm
Locu
st
I-25
4Albuquerque
Imaging Center
1 23
HeartHospital
I-40
EmbassySuites
NORTH
NORTH
Jeff
ers
on
Fox andHound
Boston’s
PF Chang’s
Bank
The 25 Way
Entrance
Jefferson
Shops@25
SingerThe 25 Way
I-25
Fronta
ge Road
South
HIGHRESOLUTION
RAAIMAGINNG
CT, Fluoroscopy, IVP, Nuclear Medicine,X-Ray, Color-Doppler, Neuro-Doppler,Neuro-Pediatric, Guided Biopsy,Spect Imaging, I-131 Therapy,Interventional and Ultrasound
HIGH RESOLUTION
Provides MR onlyOpen MR at this location
BSGI, DEXA, Mammography, MR and Ultrasound (breast & pelvic)
CT, Fluoroscopy, General Ultrasound and X-Ray
CT, Fluoroscopy, IVP, Nuclear Medicine, X-Ray, Spect Imaging, I-131 Therapy andUltrasound
DEXA, CT, MR,X-Ray and Ultrasound
44. Presbyterian Kaseman Hospital 291-2462 8300 Constitution NE, Albuquerque, NM 87110
PresbyterianHospital
Central
Ced
ar
Silver
OakI-25
55. Presbyterian Rio Rancho Radiology 462-8815 4100 High Resort Boulevard, Rio Rancho, NM 87124
Constitution
I-40
Wyo
min
g
Constitution Place
Pen
nsyl
vani
a
PresbyterianKasemanHospital
PresbyterianRio RanchoRadiology
High Resort Blvd.
Rio
Ran
cho
Blvd
.
The total cost of an X-ray is comprised of two fees: the Technical Fee covers the use of equipment,supplies and technical personnel. The Professional Fee is for reading the images or performing a procedure.Radiologists bill separately for their professional services.Please feel free to discuss your bill with us: 505-332-6900
RAA IMAGING
RAA, PA p rov ides p ro fess iona l rad io logy ser v ices to the fo l low ing Presby te r ian loca t ions :
2
3
Your appointment is scheduled at the location checked below:
1. Albuquerque Imaging Center 243-4401 4 Woodward Center 700 Lomas NE Albuquerque, NM 87102
2. High Resolution RAA Imaging 332-5800 4411 The 25 Way NE Suite 150 Albuquerque, NM 87109
3. Presbyterian Hospital 841-1181 1100 Central SE, Albuquerque, NM 87106
1
Lomas
Hig
h S
t.
Woodward Place
WoodwardCenter
MLK Elm
Locu
st
I-25
4Albuquerque
Imaging Center
1 23
HeartHospital
I-40
EmbassySuites
NORTH
NORTH
Jeff
ers
on
Fox andHound
Boston’s
PF Chang’s
Bank
The 25 Way
Entrance
Jefferson
Shops@25
SingerThe 25 Way
I-25
Fronta
ge Road
South
HIGHRESOLUTION
RAAIMAGINNG
CT, Fluoroscopy, IVP, Nuclear Medicine,X-Ray, Color-Doppler, Neuro-Doppler,Neuro-Pediatric, Guided Biopsy,Spect Imaging, I-131 Therapy,Interventional and Ultrasound
HIGH RESOLUTION
Provides MR onlyOpen MR at this location
BSGI, DEXA, Mammography, MR and Ultrasound (breast & pelvic)
CT, Fluoroscopy, General Ultrasound and X-Ray
CT, Fluoroscopy, IVP, Nuclear Medicine, X-Ray, Spect Imaging, I-131 Therapy andUltrasound
DEXA, CT, MR,X-Ray and Ultrasound
44. Presbyterian Kaseman Hospital 291-2462 8300 Constitution NE, Albuquerque, NM 87110
PresbyterianHospital
Central
Ced
ar
Silver
OakI-25
55. Presbyterian Rio Rancho Radiology 462-8815 4100 High Resort Boulevard, Rio Rancho, NM 87124
Constitution
I-40
Wyo
min
g
Constitution Place
Pen
nsyl
vani
a
PresbyterianKasemanHospital
PresbyterianRio RanchoRadiology
High Resort Blvd.
Rio
Ran
cho
Blvd
.
The total cost of an X-ray is comprised of two fees: the Technical Fee covers the use of equipment,supplies and technical personnel. The Professional Fee is for reading the images or performing a procedure.Radiologists bill separately for their professional services.Please feel free to discuss your bill with us: 505-332-6900
RAA IMAGING
RAA, PA p rov ides p ro fess iona l rad io logy ser v ices to the fo l low ing Presby te r ian loca t ions :
2
3
Your appointment is scheduled at the location checked below:
1. Albuquerque Imaging Center 243-4401 4 Woodward Center 700 Lomas NE Albuquerque, NM 87102
2. High Resolution RAA Imaging 332-5800 4411 The 25 Way NE Suite 150 Albuquerque, NM 87109
3. Presbyterian Hospital 841-1181 1100 Central SE, Albuquerque, NM 87106
1
Lomas
Hig
h S
t.
Woodward Place
WoodwardCenter
MLK Elm
Locu
st
I-25
4Albuquerque
Imaging Center
1 23
HeartHospital
I-40
EmbassySuites
NORTH
NORTH
Jeff
ers
on
Fox andHound
Boston’s
PF Chang’s
Bank
The 25 Way
Entrance
Jefferson
Shops@25
SingerThe 25 Way
I-25
Fronta
ge Road
South
HIGHRESOLUTION
RAAIMAGINNG
CT, Fluoroscopy, IVP, Nuclear Medicine,X-Ray, Color-Doppler, Neuro-Doppler,Neuro-Pediatric, Guided Biopsy,Spect Imaging, I-131 Therapy,Interventional and Ultrasound
HIGH RESOLUTION
Provides MR onlyOpen MR at this location
BSGI, DEXA, Mammography, MR and Ultrasound (breast & pelvic)
CT, Fluoroscopy, General Ultrasound and X-Ray
CT, Fluoroscopy, IVP, Nuclear Medicine, X-Ray, Spect Imaging, I-131 Therapy andUltrasound
DEXA, CT, MR,X-Ray and Ultrasound
44. Presbyterian Kaseman Hospital 291-2462 8300 Constitution NE, Albuquerque, NM 87110
PresbyterianHospital
Central
Ced
ar
SilverO
akI-25
55. Presbyterian Rio Rancho Radiology 462-8815 4100 High Resort Boulevard, Rio Rancho, NM 87124
Constitution
I-40W
yom
ing
Constitution Place
Pen
nsyl
vani
a
PresbyterianKasemanHospital
PresbyterianRio RanchoRadiology
High Resort Blvd.
Rio
Ran
cho
Blvd
.
The total cost of an X-ray is comprised of two fees: the Technical Fee covers the use of equipment,supplies and technical personnel. The Professional Fee is for reading the images or performing a procedure.Radiologists bill separately for their professional services.Please feel free to discuss your bill with us: 505-332-6900
RAA IMAGING
RAA, PA p rov ides p ro fess iona l rad io logy ser v ices to the fo l low ing Presby te r ian loca t ions :
528
528
PATIENT ENTRANCES
Westside Blvd.
Rio Rancho
Southern Blvd. SE
High Resort Presbyterian
Golf
Cour
se R
d. SE
Unse
r Blv
d. SE
Westside Blvd.
remem
ber:
we ac
cept
blu
e cro
ss
blue shie
ld at raa l
ocat
ions!
RAA, PA provides professional radiology services to the following Presbyterian locations:
1
2
3
4
5
6
Wellspring Blvd
Phone: 253-1070Fax: 253-1409
Phone: 462-8789Fax: 253-1409
Phone: 291-2462Fax: 291-2671
Phone: 841-1181Fax: 841-1180
