MRI Order Form

* The "MRI Order Form" below is for referring physicians and providers only.
* Patients seeking to schedule an MRI should consult their physician's office.

Fields marked with an asterick (*) are required.

Preferred Location *
First Available Gastonia Open

Appointment Scheduled By *

Phone *

Email *

Preferred Date

Preferred Time

First Name, Middle Initial *

Last Name *

*For authorizations, please use the following: NPI # 1356324487; Tax ID # 560988142 (Gaston Radiology) Billing Address: 336 Burtonwood Dr, Gastonia, NC 28054

Insurance *

Authorization # *

Insurance 2

Authorization # 2

Height

Weight *

Social Security Number *

Date of Birth*

Home Phone *

Other Phone

Send CD w/ patient?

Yes No

Previous Study/Location

Ordering Physician
Electronic Signature *

Note: By signing this field with your full name, you attest that all information in this patient order is accurate.

Special Instructions or Needs

List Relevant Surgeries

History of Cancer?

Yes No

Suffer From Claustrophobia?

Yes No

Any Chance of Pregnancy?

Yes No

Date of Last Menstrual Period

Orbital X-Rays Required for History of Metal Work?

Yes if needed No

Metal objects in body? Please check all that apply.

Pacemaker Aneurysm Clip Implant Stent Other

Allergies?

Yes No

Diagnosis/Symptoms

At least one item in this list is required. View ICD-10 Codes

Head / Neck: MRI Brain

Name		CPT	ICD-10
	MRI - brain w/o	70551
	MRI - brain with	70552
	MRI - brain w/o & w	70553
	MRI - other - IAC / Pituitary / Trigeminal	70553

Head / Neck: MRI Orbit Face & Neck

	MRI - TMJ	70336
	MRI - orbit, face, neck w/o	70540
	MRI - orbit, face, neck with	70542
	MRI - orbit, face, and neck w/o & w	70543

Head/Neck: MR Angiography

	MRA - head w/o	70544
	MRA - neck w/o	70547
	MRA - neck with	70548
	MRA - neck w/o & w	70549

Spine: MRI Spinal Canal

	MRI - C-spine w/o	72141
	MRI - C-spine with	72142
	MRI - C-spine w/o & w	72156
	MRI - L-spine w/o	72148
	MRI - L-spine with	72149
	MRI - L-spine w/o & w	72158
	MRI - T-spine w/o	72146
	MRI - T-spine with	72147
	MRI - T-spine w/o & w	72157
	MRI - sacrum	72195

** MRI Any Joint / Extremity **

MRI OF

Name

CPT

ICD-10

R L MRI - Arthrogram of

R L MRI - upper extremity (OTJ) w/o

73218

R L MRI - upper extremity (OTJ) with

73219

R L MRI - upper extremity (OTJ) w/o & w

73220

R L MRI - upper extremity (joint) w/o

73221

R L MRI - upper extremity (joint) with

73222

R L MRI - upper extremity (joint) w/o & w

73223

R L MRI - upper extremity with or w/o

73225

R L MRI - lower extremity (OTJ) w/o

73718

R L MRI - lower extremity (OTJ) with

73719

R L MRI - lower extremity (OTJ) w/o & w

73720

R L MRI - lower extremity (joint) w/o

73721

R L MRI - lower extremity (joint) with

73722

R L MRI - lower extremity (joint) w/o & w

73723

R L MRA - lower extremity with or w/o

73725

R L MRI - Brachial Plexus

Body: Chest

	MRI - chest w/o	71550
	MRI - chest with	71551
	MRI - chest w/o & w	71552
	MRA - chest / aorta	71555

Body: Abdomen/Pelvis

	MRI - abdomen w/o	74181
	MRI - abdomen with	74182
	MRI - abdomen w/o & w	74183
	MRA Abdomen with or w/o	74185
	MRI - pelvis w/o	72195
	MRI - pelvis with	72196
	MRI - pelvis w/o & w	72197
	MRA - pelvis with or w/o	72198

MRI OTHER

MRI - other of

Contrast at Radiologist Discretion

Contrast requires a Creatinine for anyone over 60, diabetes, kidney disease, chemotherapy, etc* This can be done onsite prior to start of exam.

** Extremities / Joints with history of infection, abscess, ulcer, cyst or mass usually require w/o & w contrast agent per radiologist.

Federal Necessity: Federal Regulations require that only the tests that are necessary for diagnosis and treatment of a patient’s condition be ordered. The ICD-9 code is required to prove medical necessity.