Please fill out the following form, 1 patient per form. Multiple services may be entered for each patient. Fields in bold are required and must be filled in.

Last Name:
First Name:
MI:
DOB:
Address:
City:
State:	Select a State.. Alabama Alaska Arizona Arkansas California Colorado Connecticut Deleware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusettes Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip:
Home Phone:	- -
Work Phone:	- - x
Amputee? Yes No Claustrophobic? Yes No Pregnant? Yes No Any type of metal in the body? Yes No Pacemaker? Yes No Surgery in the area being scanned? Yes No Work with metal? Yes No History of diabetes? Yes No History of cancer? Yes No Previous studies of the area being scanned? Yes No
Height:	-
Weight:	lbs.

Referring Physician:	Dr.
Phone Number:	- -

Modality	Region	Rule Out
Select a Modality.. BAEP BAEP Limited Bone Scan CT EEG EEG EEG Greater than 1 hour EEG recording awake and asleep EEG recording awake and drowsy EMG H-reflex, amplitude and latency study Mammogram MR Arthrography MRA MRI MRV Muscle Testing Manual with report; extremity or trunk NCV Needle electromyography crainal nerve bilaterial Needle electromyography crainal nerve unilaterals Needle electromyography four extremities Needle electromyography limited studay of muscles Needle electromyography one extremity Needle electromyography thoracic paraspinal muscles Needle electromyography three extremities Needle electromyography two extremities Nerve Conduction Sensory Mixed Nerve Conduction with F waves Nerve Conduction without F waves None OFFIC CONS NEW/ESTAB MOD-HIGH SEVERITY 60 MIN OFFIC CONS NEW/ESTAB MOD-HIGH SEVERITY 80 MIN OFFIC CONS NEW/ESTAB MODERATE SEVERITY 40 MIN OFFIC/OUTPT VISIT E&M EST LOW-MOD SEVERITY 15 MIN OFFIC/OUTPT VISIT E&M EST MOD-HI SEVERITY 25 MIN OFFIC/OUTPT VISIT E&M EST SELF-LIMIT/MINOR 10 MIN OFFIC/OUTPT VISIT E&M ESTAB MOD-HI SEVRTY 40 MIN OFFIC/OUTPT VISIT E&M ESTAB NO PHYS PRES 5 MIN OFFIC/OUTPT VISIT E&M NEW MOD-HI SEVERITY 45 MIN OFFIC/OUTPT VISIT E&M NEW MOD-HI SEVERITY 60 MIN OFFIC/OUTPT VISIT E&M NEW MODERAT SEVERITY 30 MIN OFFICE CONS NEW/ESTAB LOW SEVERITY 30 MIN Range of Motion measurements and report, extremity or trunk Short-latency somatosensory study Short-latency somatosensory study in lower limbs Short-latency somatosensory study in trunk or head Ultrasound VEP testing X-ray	Select a Region.. Abdomen Body Brain Cervical Spine Chest Dorsal Head Left Ankle Left Foot Left Hip Left Knee Left Shoulder Left Wrist Lower Extremities Lumbar Spine Maxillofacial Multiple None Orbit Orbit Face/Neck Other Pelvis Right Ankle Right Foot Right Hip Right Knee Right Shoulder Right Wrist Temporomandibular Joint(s) Thoracic Spine Upper Extremities
Select a Modality.. BAEP BAEP Limited Bone Scan CT EEG EEG EEG Greater than 1 hour EEG recording awake and asleep EEG recording awake and drowsy EMG H-reflex, amplitude and latency study Mammogram MR Arthrography MRA MRI MRV Muscle Testing Manual with report; extremity or trunk NCV Needle electromyography crainal nerve bilaterial Needle electromyography crainal nerve unilaterals Needle electromyography four extremities Needle electromyography limited studay of muscles Needle electromyography one extremity Needle electromyography thoracic paraspinal muscles Needle electromyography three extremities Needle electromyography two extremities Nerve Conduction Sensory Mixed Nerve Conduction with F waves Nerve Conduction without F waves None OFFIC CONS NEW/ESTAB MOD-HIGH SEVERITY 60 MIN OFFIC CONS NEW/ESTAB MOD-HIGH SEVERITY 80 MIN OFFIC CONS NEW/ESTAB MODERATE SEVERITY 40 MIN OFFIC/OUTPT VISIT E&M EST LOW-MOD SEVERITY 15 MIN OFFIC/OUTPT VISIT E&M EST MOD-HI SEVERITY 25 MIN OFFIC/OUTPT VISIT E&M EST SELF-LIMIT/MINOR 10 MIN OFFIC/OUTPT VISIT E&M ESTAB MOD-HI SEVRTY 40 MIN OFFIC/OUTPT VISIT E&M ESTAB NO PHYS PRES 5 MIN OFFIC/OUTPT VISIT E&M NEW MOD-HI SEVERITY 45 MIN OFFIC/OUTPT VISIT E&M NEW MOD-HI SEVERITY 60 MIN OFFIC/OUTPT VISIT E&M NEW MODERAT SEVERITY 30 MIN OFFICE CONS NEW/ESTAB LOW SEVERITY 30 MIN Range of Motion measurements and report, extremity or trunk Short-latency somatosensory study Short-latency somatosensory study in lower limbs Short-latency somatosensory study in trunk or head Ultrasound VEP testing X-ray	Select a Region.. Abdomen Body Brain Cervical Spine Chest Dorsal Head Left Ankle Left Foot Left Hip Left Knee Left Shoulder Left Wrist Lower Extremities Lumbar Spine Maxillofacial Multiple None Orbit Orbit Face/Neck Other Pelvis Right Ankle Right Foot Right Hip Right Knee Right Shoulder Right Wrist Temporomandibular Joint(s) Thoracic Spine Upper Extremities
Select a Modality.. BAEP BAEP Limited Bone Scan CT EEG EEG EEG Greater than 1 hour EEG recording awake and asleep EEG recording awake and drowsy EMG H-reflex, amplitude and latency study Mammogram MR Arthrography MRA MRI MRV Muscle Testing Manual with report; extremity or trunk NCV Needle electromyography crainal nerve bilaterial Needle electromyography crainal nerve unilaterals Needle electromyography four extremities Needle electromyography limited studay of muscles Needle electromyography one extremity Needle electromyography thoracic paraspinal muscles Needle electromyography three extremities Needle electromyography two extremities Nerve Conduction Sensory Mixed Nerve Conduction with F waves Nerve Conduction without F waves None OFFIC CONS NEW/ESTAB MOD-HIGH SEVERITY 60 MIN OFFIC CONS NEW/ESTAB MOD-HIGH SEVERITY 80 MIN OFFIC CONS NEW/ESTAB MODERATE SEVERITY 40 MIN OFFIC/OUTPT VISIT E&M EST LOW-MOD SEVERITY 15 MIN OFFIC/OUTPT VISIT E&M EST MOD-HI SEVERITY 25 MIN OFFIC/OUTPT VISIT E&M EST SELF-LIMIT/MINOR 10 MIN OFFIC/OUTPT VISIT E&M ESTAB MOD-HI SEVRTY 40 MIN OFFIC/OUTPT VISIT E&M ESTAB NO PHYS PRES 5 MIN OFFIC/OUTPT VISIT E&M NEW MOD-HI SEVERITY 45 MIN OFFIC/OUTPT VISIT E&M NEW MOD-HI SEVERITY 60 MIN OFFIC/OUTPT VISIT E&M NEW MODERAT SEVERITY 30 MIN OFFICE CONS NEW/ESTAB LOW SEVERITY 30 MIN Range of Motion measurements and report, extremity or trunk Short-latency somatosensory study Short-latency somatosensory study in lower limbs Short-latency somatosensory study in trunk or head Ultrasound VEP testing X-ray	Select a Region.. Abdomen Body Brain Cervical Spine Chest Dorsal Head Left Ankle Left Foot Left Hip Left Knee Left Shoulder Left Wrist Lower Extremities Lumbar Spine Maxillofacial Multiple None Orbit Orbit Face/Neck Other Pelvis Right Ankle Right Foot Right Hip Right Knee Right Shoulder Right Wrist Temporomandibular Joint(s) Thoracic Spine Upper Extremities
Select a Modality.. BAEP BAEP Limited Bone Scan CT EEG EEG EEG Greater than 1 hour EEG recording awake and asleep EEG recording awake and drowsy EMG H-reflex, amplitude and latency study Mammogram MR Arthrography MRA MRI MRV Muscle Testing Manual with report; extremity or trunk NCV Needle electromyography crainal nerve bilaterial Needle electromyography crainal nerve unilaterals Needle electromyography four extremities Needle electromyography limited studay of muscles Needle electromyography one extremity Needle electromyography thoracic paraspinal muscles Needle electromyography three extremities Needle electromyography two extremities Nerve Conduction Sensory Mixed Nerve Conduction with F waves Nerve Conduction without F waves None OFFIC CONS NEW/ESTAB MOD-HIGH SEVERITY 60 MIN OFFIC CONS NEW/ESTAB MOD-HIGH SEVERITY 80 MIN OFFIC CONS NEW/ESTAB MODERATE SEVERITY 40 MIN OFFIC/OUTPT VISIT E&M EST LOW-MOD SEVERITY 15 MIN OFFIC/OUTPT VISIT E&M EST MOD-HI SEVERITY 25 MIN OFFIC/OUTPT VISIT E&M EST SELF-LIMIT/MINOR 10 MIN OFFIC/OUTPT VISIT E&M ESTAB MOD-HI SEVRTY 40 MIN OFFIC/OUTPT VISIT E&M ESTAB NO PHYS PRES 5 MIN OFFIC/OUTPT VISIT E&M NEW MOD-HI SEVERITY 45 MIN OFFIC/OUTPT VISIT E&M NEW MOD-HI SEVERITY 60 MIN OFFIC/OUTPT VISIT E&M NEW MODERAT SEVERITY 30 MIN OFFICE CONS NEW/ESTAB LOW SEVERITY 30 MIN Range of Motion measurements and report, extremity or trunk Short-latency somatosensory study Short-latency somatosensory study in lower limbs Short-latency somatosensory study in trunk or head Ultrasound VEP testing X-ray	Select a Region.. Abdomen Body Brain Cervical Spine Chest Dorsal Head Left Ankle Left Foot Left Hip Left Knee Left Shoulder Left Wrist Lower Extremities Lumbar Spine Maxillofacial Multiple None Orbit Orbit Face/Neck Other Pelvis Right Ankle Right Foot Right Hip Right Knee Right Shoulder Right Wrist Temporomandibular Joint(s) Thoracic Spine Upper Extremities
Select a Modality.. BAEP BAEP Limited Bone Scan CT EEG EEG EEG Greater than 1 hour EEG recording awake and asleep EEG recording awake and drowsy EMG H-reflex, amplitude and latency study Mammogram MR Arthrography MRA MRI MRV Muscle Testing Manual with report; extremity or trunk NCV Needle electromyography crainal nerve bilaterial Needle electromyography crainal nerve unilaterals Needle electromyography four extremities Needle electromyography limited studay of muscles Needle electromyography one extremity Needle electromyography thoracic paraspinal muscles Needle electromyography three extremities Needle electromyography two extremities Nerve Conduction Sensory Mixed Nerve Conduction with F waves Nerve Conduction without F waves None OFFIC CONS NEW/ESTAB MOD-HIGH SEVERITY 60 MIN OFFIC CONS NEW/ESTAB MOD-HIGH SEVERITY 80 MIN OFFIC CONS NEW/ESTAB MODERATE SEVERITY 40 MIN OFFIC/OUTPT VISIT E&M EST LOW-MOD SEVERITY 15 MIN OFFIC/OUTPT VISIT E&M EST MOD-HI SEVERITY 25 MIN OFFIC/OUTPT VISIT E&M EST SELF-LIMIT/MINOR 10 MIN OFFIC/OUTPT VISIT E&M ESTAB MOD-HI SEVRTY 40 MIN OFFIC/OUTPT VISIT E&M ESTAB NO PHYS PRES 5 MIN OFFIC/OUTPT VISIT E&M NEW MOD-HI SEVERITY 45 MIN OFFIC/OUTPT VISIT E&M NEW MOD-HI SEVERITY 60 MIN OFFIC/OUTPT VISIT E&M NEW MODERAT SEVERITY 30 MIN OFFICE CONS NEW/ESTAB LOW SEVERITY 30 MIN Range of Motion measurements and report, extremity or trunk Short-latency somatosensory study Short-latency somatosensory study in lower limbs Short-latency somatosensory study in trunk or head Ultrasound VEP testing X-ray	Select a Region.. Abdomen Body Brain Cervical Spine Chest Dorsal Head Left Ankle Left Foot Left Hip Left Knee Left Shoulder Left Wrist Lower Extremities Lumbar Spine Maxillofacial Multiple None Orbit Orbit Face/Neck Other Pelvis Right Ankle Right Foot Right Hip Right Knee Right Shoulder Right Wrist Temporomandibular Joint(s) Thoracic Spine Upper Extremities
Select a Modality.. BAEP BAEP Limited Bone Scan CT EEG EEG EEG Greater than 1 hour EEG recording awake and asleep EEG recording awake and drowsy EMG H-reflex, amplitude and latency study Mammogram MR Arthrography MRA MRI MRV Muscle Testing Manual with report; extremity or trunk NCV Needle electromyography crainal nerve bilaterial Needle electromyography crainal nerve unilaterals Needle electromyography four extremities Needle electromyography limited studay of muscles Needle electromyography one extremity Needle electromyography thoracic paraspinal muscles Needle electromyography three extremities Needle electromyography two extremities Nerve Conduction Sensory Mixed Nerve Conduction with F waves Nerve Conduction without F waves None OFFIC CONS NEW/ESTAB MOD-HIGH SEVERITY 60 MIN OFFIC CONS NEW/ESTAB MOD-HIGH SEVERITY 80 MIN OFFIC CONS NEW/ESTAB MODERATE SEVERITY 40 MIN OFFIC/OUTPT VISIT E&M EST LOW-MOD SEVERITY 15 MIN OFFIC/OUTPT VISIT E&M EST MOD-HI SEVERITY 25 MIN OFFIC/OUTPT VISIT E&M EST SELF-LIMIT/MINOR 10 MIN OFFIC/OUTPT VISIT E&M ESTAB MOD-HI SEVRTY 40 MIN OFFIC/OUTPT VISIT E&M ESTAB NO PHYS PRES 5 MIN OFFIC/OUTPT VISIT E&M NEW MOD-HI SEVERITY 45 MIN OFFIC/OUTPT VISIT E&M NEW MOD-HI SEVERITY 60 MIN OFFIC/OUTPT VISIT E&M NEW MODERAT SEVERITY 30 MIN OFFICE CONS NEW/ESTAB LOW SEVERITY 30 MIN Range of Motion measurements and report, extremity or trunk Short-latency somatosensory study Short-latency somatosensory study in lower limbs Short-latency somatosensory study in trunk or head Ultrasound VEP testing X-ray	Select a Region.. Abdomen Body Brain Cervical Spine Chest Dorsal Head Left Ankle Left Foot Left Hip Left Knee Left Shoulder Left Wrist Lower Extremities Lumbar Spine Maxillofacial Multiple None Orbit Orbit Face/Neck Other Pelvis Right Ankle Right Foot Right Hip Right Knee Right Shoulder Right Wrist Temporomandibular Joint(s) Thoracic Spine Upper Extremities

Carrier:	Select a Carrier.. *Lady Insurance-WC AIG (Garden City, NY) AIG Claim Services (WC-GA) AIG Claims Services-POBox1822(Alpharetta,GA) NY AIG Claims Services-WC AIG Insurance-Albany AIG-NY Pilot AIU Ins Co./American Home Allstate / NY Allstate Insurance Concentra Allstate-NJ-Concentra-AIONY American Home Assurance Co./NY American Independent Insurance Co(for NY) American Transit Insurance Company Amherst WC Claims Atlantic Imaging Group - Workers Comp Atlantic Imaging of New York, P.C. - Workers Comp Auto One (NY) Blue Cross Blue Shield Western NY Bristol Insurance Company/NY Cambridge Intergrated Services Chubb Group of Insurance Companies-PA Chubb Services Corporation-NY Chubb-NY Claims Corp./NY Clarendon National /NY Coach USA / MES Coast National Insurance Co. Colonial Penn/NY Cool Risk Management Services Cool Risk Management Services Country Wide Ins. Co. Crawford & Company (NY WC) Crum and Foster Cypress Care, Inc.-NY-Auto Cypress Care, Inc.-NY-WC Demo Demo Elco Administrative Services Electric Insurance Company Empire BC BS Encompass Insurance Company-NY FCS Administrators First Niagara Fitzharris Agency Gallagher Basset Services (for NY) Geico - in NY (for NY Auto) (PO Box 116) GEICO-Prizm NY General Assurance Co. GMAC/NY Hartford Insurance Company (for NY) Hereford insurance Co./NY HIP-HC HIP-WC Hudson Insurance Co./Countrywide Management Co. Independent Health Ins. Independent Review Services - Genex Jefferson County Department of Insurance and Safety Kemper Unitrin Direct Liberty Mutual Group-WC Liberty Mutual WC - Tarrytown NY Liberty Mutual-Auto-NJ-AIONY Liberty Mutual/203 Mitchellfield/Uniondale Liberty Mutual/211 Elmsford Liberty Mutual/221 Islandia Liberty Mutual/274 Buffalo Liberty Mutual/275 Albany Liberty Mutual/Uniondale Lovell Safety / NYSIF MAGNA COMP Meraster Merchants Mutual Mercury Insurance (for NJ pts w/ FL policy) Metlife Auto & Home / NY Metlife-NJ-(NY) National Continental Insurance Company (NY auto) National Grange Mutual Nationwide Insurance Neuman Claim Admin New York Central Mutual New York Central Mutual Fire Insurance Company New York City Law Department Workers Compensation Division NJM-NY North American Risk NY Test Carrier NYSIF NYSIF-Albany NYSIF-Buffalo NYSIF-Glendale NYSIF-Nassau NYSIF-NYC (Metro 90) NYSIF-NYC (NYC Division) NYSIF-NYC (Safety Group 1) NYSIF-NYC (Safety Group 2) NYSIF-Rochester NYSIF-Suffolk NYSIF-Syracuse/Liverpool NYSIF-White Plains NYSIF-White Plains for NJ Claims Ohio Casualty/NY (auto) One Beacon Insurance Palisades Safety & Insurance-NY Parkway Ins. / Genex (NY) Peerless Insurance Co. Progressive Ins. (NY auto-in NY) Progressive Medical WC Prudential/Liberty Mutual-NY Responce Insurance Company RSKO Rutgers Casualty-New York Safe Auto Insurance (NY auto) Sedgwick Ins.-Auto Sedgwick Ins.-WC Sedgwick/Con Edison Sentry Insurance-NY Special Funds Special Funds-Buffalo St. Paul Insurance Company State Farm(out of state)-Box926-Parsippany State Farm/NY(PO Box 820-Ballston Spa) State Farm/NY(PO Box 905-Parsippany) Superior Insurance Group The Black Car Fund The Black Car Fund WC The Risk Management Planning Group, Inc. Travelers Insurance - NY Travelers Insurance-MD Tri State Insurance Co. Trumbull Insurance Company U.S. Department of Labor-NJ (London KY) U.S. Department of Labor-NY USAA-NY Vanguard-NY Auto (in NJ) Wellchoice York Claim Services (NY) Zurich American Insurance (NY) Zurich Services Corporation
Carrier Reference #:
Claim Number:
Claim Type:	Auto Workers Comp

Name:
Phone Number:	- - x
Notes:

Email Address: