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(06/2017) Form #85071 ____ Arterial Blood Gas/Co-Ox ____ Oximeter Exercise Study ____ Other ______________________ ____ DLCO* ____ Lung Volumes* ____ Pre/Post Bronchodilators* ____ Spirometry* ____ Complete ( ) ____ Methacholine Challenge ____ EEG ____ Sedated EEG (H & P Required) ____ BAER ____ Sedated BAER (H & P Required) ____ VER ____ SER ____ NCV - Upper Extremity: R__ L__ ____ NCV - Lower Extremity: R__ L__ ____ EMG - Upper Extremity: R__ L__ ____ EMG - Lower Extremity: R__ L__ ____ Polysomnograph (NPSG) (H & P Required) ____ CPAP Study ____ MSLT/MWT (Multiple Sleep Latency/ Maintainence of Wakefulness) ____ CPAP Clinic ____ Sleep Clinic ______Physical Therapy ______________________________ ______Occupational Therapy __________________________ ______Speech Therapy _______________________________ ____ Medical Nutrition Therapy (Nutrition Assessment/Consultation) Specify diet _________________________________________ ___________________________________________________ ____ Blood transfusions ____Wound Care Suite ____ Injections ____ RhoGam ____ Hydration/IV Infusion ____ Other ________________________ ____ Gastroscopy ____ Esophageal Dilatation ____ Colonoscopy ____ Bronchoscopy ____ Flex. Sigmoidoscopy ____ ph Probe ____ ERCP ____ Other___________________________ _____ Venous Lower Ext. Bilat _____ Arterial Doppler Lower _____ Venous Lower Ext. R__ L__ _____ Arterial Doppler Lower _____ Venous Upper Ext. Bilat w/ Exercise _____ Venous Upper Ext. R__ L__ _____ Arterial Doppler Upper _____ ABI - Limited Arterial Study _____ Carotid Duplex Exam _____ Other ______________________________________ _____ EKG _____ Rhythm Strip _____ ECHOcardiogram _____Exercise Stress Test _____ TEE _____Nuclear Exercise Stress Test _____ Stress Echo _____Persantine Stress Test _____ Event Monitor _____Adenosine Stress Test _____ Dobutamine Stress _____ Cardiac Event Monitor Echo _____ Ambulatory BP Monitor _____ 24 Hour Holter Monitor _____ Other ______________________________________ PATIENT’S LEGAL NAME DATE OF BIRTH PATIENT SIGNS/SYMPTOMS SPECIAL INSTRUCTIONS PHYSICIAN NAME (please print) ORDERING PHYSICIAN’S SIGNATURE DATE/TIME ❑ CALL REPORT TO_____________________________________ ❑ FAX REPORT TO______________________________________ PATIENT PHONE INSURANCE COMPANY NAME PHYSICIAN OFFICES Tests cannot be performed without listing the signs/symptoms and/or reason(s) for each test ordered along with the ICD-10 code. Federal law requires that we inform you when ordering tests that will be paid under federal health programs, including Medicare and Medicaid, physicians should only order tests that are medically necessary for diagnosis or treatment of the patient, not for screening purposes. Signature Stamps Are Not Valid X OUTPATIENT ORDER FORM OUTPATIENT SERVICES Appt. Date: _____________________ Appt. Time: _____________________ Arrival Time: _____________________ MAIN HOSPITAL 1230 Baxter St., Athens, GA OUTPATIENT DIAGNOSTIC CENTER 2470 Daniells Bridge Rd., Athens, GA TO SCHEDULE: 706.389.2700 FAX this order and required clinical records to: 706.389.2001 Your office will be contacted prior to test being performed if form is not complete. ICD-10 CODE:
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