Referral Form
CALL 800-626-8315, FAX 800-650-0615, OR EMAIL This e-mail address is being protected from spambots. You need JavaScript enabled to view it TO SCHEDULE AN APPOINTMENT
Appointment Date_______________________________ Appointment Time__________________________________________
Patient Name____________________________________ Phone #__________________________________________________
Report to additional physician(s)_____________________________________________________________________________
Clinical History/Diagnosis___________________________________________________________________________________
Referring Physician________________________________________________________________________________________
Referring Physician Signature________________________________________________________________________________
Phone#_________________________________Fax#______________________________E-mail__________________________
EXAMINATION TYPE: X-RAY ULTRASOUND/ECHO ULTRASOUND GUIDED PROCEDURE
BODY PART: ________________________________________________________________________________________________________________________________
ICD-9 CODE & HISTORY: ______________________________________________________________________________________________________________________
Special Instructions ___________________________________________________________________________________________________________________________
EXAMINATION TYPE: X-RAY ULTRASOUND/ECHO ULTRASOUND GUIDED PROCEDURE
BODY PART: ________________________________________________________________________________________________________________________________
ICD-9 CODE & HISTORY: ______________________________________________________________________________________________________________________
Special Instructions ___________________________________________________________________________________________________________________________
EXAMINATION TYPE: X-RAY ULTRASOUND/ECHO ULTRASOUND GUIDED PROCEDURE
BODY PART: ________________________________________________________________________________________________________________________________
ICD-9 CODE & HISTORY: ______________________________________________________________________________________________________________________
SPECIAL INSTRUCTIONS: _____________________________________________________________________________________________________________________
EXAMINATION TYPE: X-RAY ULTRASOUND/ECHO ULTRASOUND GUIDED PROCEDURE
BODY PART: ________________________________________________________________________________________________________________________________
ICD-9 CODE & HISTORY: ______________________________________________________________________________________________________________________
SPECIAL INSTRUCTIONS: _____________________________________________________________________________________________________________________
Link to Common ICD-9 Codes for Ultrasound – http://archrad.com/icd9-ultrasound.html
Link to Common ICD-9 Codes for X-Ray – http://archrad.com/icd9-xray.html
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Archer Radiology Century City X-RAY ULTRASOUND/ECHO ULTRASOUND GUIDED PROCEDURES |
Archer Radiology Glendale: MRI ONLY |
Archer Radiology Temple Community Hospital CT SCAN ULTRASOUND X-RAY NUCLEAR MEDICINE INTERVENTIONAL RADIOLOGY |
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2080 Century Park East, Suite 1410 Los Angeles, CA 90064 T: 800-626-8315
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442 W. Broadway Suite 204 Glendale, CA 91204 T: 800-626-8315 F: 800-650-0615 |
235 N. Hoover Street Los Angeles, CA 90004 T: 800-626-8315
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