Physician Request Form - Central Park Advanced Imaging

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Physician Request Form MW Access May 18, 2025 May 23, 2025

Physician Request Form

"*" indicates required fields

Step 1 of 4

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Patient Name*

Date of Birth*

MM slash DD slash YYYY

Signs & Symptoms / ICD-10 Codes*

Requested Exam Date*

MM slash DD slash YYYY

Requested Exam Time

Hours

:

Minutes

AM/PM

Pre-Authorization / DSN No*

Name*

Email*

Address*

Phone*

Fax

STAT Read

NPI*

MRI Scan

w/o contrast

w/wo contrast

3D Recan

Arthography

Radiologist may change contrast order if clinically indicated

Brain

Orbits

IAC

Pituitary

TMJ

Soft Tissue Neck

Nasopharnyx

Cervical Spine

Thoracic Spine

Lumbar Spine

T2- Iron Overload

T2- Iron Overload - Abdomen

T2- Iron Overload - Heart

Cardiac

Adenosine Perfusion

Chest

Breast

Abdomen

Elastography

Brachial Plexus

MRCP

MRCP - with Secretin / CCK

Pelvis

Enterography

Defecography

Prostate

Shoulder - Left

Shoulder - Right

Hip - Left

Hip - Right

Knee - Left

Knee - Right

Ankle - Left

Ankle - Right

Foot - Left

Foot - Right

Other

MRI Aniography

Head

Neck (Carotid)

Chest

Abdomen

Pelvis

Extremities Lower

Extremities Upper

Perforated Flap (PFA)

Shoulder - Perforated Flap (PFA) - Abdomen / Pelvis

Perforated Flap (PFA) - Pelvis / Lower

Extremity

Other

MRI Venography

Head

Abdomen

Pelvis

Extremities Lower

Extremities Upper

Other

CT

w/ contrast

w/wo contrast

w/o contrast

3D Recan

Radiologist may change contrast order if clinically indicated

Head

Sinuses

Orbits

Temporal Bone

Facial Bones Nasopharynx

TMJ for Prostheses Fitting Neck

Chest

Lung Screening

Pulmonary Embolism Study

Cardiac

Cardiac - Congenital

Cardiac - PVI

Cardiac - Calcium Scoring Only

Cardiac - Non-Coronary

Cardiac - TAVR

Abdomen and Pelvis

Abdomen Only

Pelvis Only

Enterography

Urogram

Colonography - Virtual Colonoscopy

Cervical Spine

Thoracic Spine

Lumbar Spine

Other

CT Aniography

Cardiac

Cardiac w/ Calcium Score

Cardiac TAVR

Cardiac Add FFR

Head

Chest

Neck

Abdomen

Pelvis

Lower Extremity

Other

PET/CT

PET/CT

Other

Ultrasound

add Doppler

Abdominal

Abdominal Complete

Abdominal Limited (e.g. RUQ, LUQ, Ascites, Spleen, Appendix, Hernia)

Pelvic Transabdominal

Pelvic Transabdominal + Transvaginal

Pelvic Transvaginal

Obstetrics

Infant Hips

Infant Head

Bladder

Renal

Renal for Renal Artery Stenosis

Renal Transplant

Liver Transplant

Scrotal with Doppler

Thyroid

Aorta Screening

Aorta Diagnostic

Hysterosonography

Soft Tissue

Extremities Non-vascular (MSK)

Extremities Non-vascular (MSK) - Upper

Extremities Non-vascular (MSK) - Lower (e.g. Baker's cyst)

Extremities Non-vascular (MSK) - Right

Extremities Non-vascular (MSK) - Left

Other

Vascular

Soft Tissue

Extremities Non-vascular (MSK)

Extremities Non-vascular (MSK) - Upper

Extremities Non-vascular (MSK) - Lower (e.g. Baker's cyst)

Extremities Non-vascular (MSK) - Right

Extremities Non-vascular (MSK) - Left

Extremities Non-vascular (MSK) - Bilateral

Other

Δ

Have a question?Send us an email

info@cpaimpaging,com

Prefer to talk?Give us a call toady

(212)-363-7315

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110 East 60th St, Lower Level,
New York, NY 10022

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110 East 60th St, Lower Level, New York, NY 10022

110 East 60th St, Lower Level
New York, NY 10022

(212)-363-7315

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