DISPATCH: 623-257-1399

FAX ORDER TO: 623-257-2133

PHYSICIAN INFORMATION
Disclaimer: By typing my name and clicking Submit, I am applying my electronic signature to this order and certify that I am a licensed physician or authorized healthcare provider, that I have evaluated this patient, that the services requested are medically necessary, and that all information provided is accurate and complete. This electronic signature carries the same legal weight as a handwritten signature under the Electronic Signatures in Global and National Commerce Act (E-SIGN Act).
INSURANCE
PROCEDURES ORDERED
chest/abdomen
71110
71045
71100
71046
74018
74019
74021
spine and pelvis
72070
72170
72040
72100
72080
72200
head and neck
72210
72260
70140
70160
lower extremities
73620
73660
73552
73560
73590
73600
73501
73502
upper extremities
73070
73090
73030
73060
73000
73020
73100
73120
73140
ultrasound
76856
76870
93975
93880
76770
76882
76805
76536
76641
76604
76700
93922
93975
93923
93925
93930
93970
93970
electrocardiogram
93000
echocardiogram
93306
other exam
93224
93228
93268
93229
ATTACHMENTS

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