Diagnostic Services

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3814 East Joppa Road

Baltimore, MD 21237

FOR SCHEDULING QUESTIONS CALL

410-529-6666

410-256-1555

1-800-848-9593

FAX: 410-529-0019

THIS FORM IS A REQUEST/VERIFICATION OF ORDERS GIVEN BY THE REFERRING PHYSICIAN FOR BALTIMORE ULTRASOUND TO PERFORM PROCEDURE INDICATED BELOW

_____ 76700 ABDOMINAL ULTRASOUND/COMPLETE: INCLUDES: LIVER, GALLBLADDER, COMMON BILE DUCT, PANCREAS, SPLEEN, KIDNEYS, UPPER ABDOMINAL AORTA AND INFERIOR VENA CAVA

_____ 76705 ABDOMINAL ULTRASOUND/LIMITED: SINGLE ORGAN, QUADRANT OR FOLLOW UP

_____ 93975 ABDOMINAL DOPPLER/COMPLETE: DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMINAL OR RETROPERITONEAL ORGANS

_____ 76770 RETROPERITONEAL ULTRASOUND: INCLUDES: KIDNEYS, ABDOMINAL AORTA, COMMON ILIAC ARTERY ORIGINS AND INFERIOR VENA CAVEA

PREP FOR ALL OF THE ABOVE: NO FOOD OR DRINK FOR 6 HOURS PRIOR TO EXAM. YOU MAY DRINK A SMALL AMOUNT OF WATER

_____ 76856 PELVIC ULTRASOUND: (FEMALE) EXAMINATION OF UTERUS, ADNEXAL STRUCTURES, ENDOMETRIUM AND BLADDER

_____ 76856 PELVIC ULTRASOUND: (MALE) EXAMINATION OF URINARY BLADDER, PROSTATE AND SEMINAL VESICLES

_____ 76830 TRANSVAGINAL ULTRASOUND

PREP: PATIENTS MUST HAVE A FULL BLADDER. SHOULD BE FINISHED DRINKING 32OZ OF WATER ONE HOUR BEFORE APPOINTMENT TIME. DO NOT EMPTY BLADDER ONCE YOU HAVE STARTED DRINKING.

_____ OBSTETRICAL ULTRASOUND: PREGNANT UTERUS FETAL AND MATERNAL EVALUATION

PREP: PREGNANCIES UP TO 25 WKS DRINK 16 OZ OF FLUID ONE HOUR BEFORE EXAM AND DO NOT EMPTY YOUR BLADDER UNTIL TEST IS COMPLETE. 26 WKS OR MORE, NO SPECIAL PREP

_____ 76870 SCROTUM AND CONTENTS ULTRASOUND

_____ 93975 SCROTAL DOPPLER/COMPLETE: DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF PENILE VESSELS

_____ 76536 THYROID ULTRASOUND: SOFT TISSUES OF HEAD AND NECK

_____ 93880 CAROTID ULTRASOUND/COMPLETE BILATERAL STUDY: DUPLEX SCAN OF EXTRACRANIAL ARTERIES

_____ 93970 VENOUS EXTREMITY COMPLETE BILATERAL STUDY: DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS

_____ 93971 VENOUS EXTREMITY: UNILATERAL OR LIMITED

_____ 93306 ECHOCARDIOGRAM: TRANSTHORACIC, REAL TIME WITH IMAGE DOCUMENTATION 2D INCLUDES M-MODE RECORDING WITH SPECTRAL DOPPLER AND COLOR FLOW

_____ 93923 ARTERIAL UPPER OR LOWER BILATERAL EXTREMITY ARTERIES 3 OR MORE ARTERIES

_____ 93925 ARTERIAL LOWER BILATERAL DUPLEX SCAN OF EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS

_____ 93926 ARTERIAL LOWER UNILATERAL DUPLEX SCAN OF EXTREMITY

_____ 93930 ARTERIAL UPPER BILATERAL DUPLEX SCAN OF EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS

_____ 93931 ARTERIAL UPPER UNILATERAL DUPLEX SCAN OF ARTERIES

_____ 76881 EXTREMITY ULTRASOUND/COMPLETE: NONVASCULAR, REAL TIME WITH IMAGE DOCUMENTATION