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					                     OHSU Imaging Services Research Exam Order Form
            Scheduling Phone: (503) 418-0990        Fax to: (503) 494-4621 or 494-5020     Do NOT enter in Epic

            DEPARTMENT: CT SCAN                     INDUSTRIAL ACCOUNT #
                                                    MED. REC. NO.
  ATTENDING PHYSICIAN                               PT. NAME
                                                    BIRTH DATE
  _____________________________________
  Physician Signature                               RESEARCH CONTACT & PHONE #
SIGNS & SYMPTOMS
                                                    REFERRING DEPARTMENT
                                                    ORDERER NAME & PHONE #
REASON FOR EXAM / HISTORY
                                                    Desired machine:
Exam to be read by Radiologist?
DESIRED EXAM DATE & TIME:
   ICD-9: V 72.6 Research patient                      INTERPRETER NEEDED TRANSPORT
   Svc                                     Svc                             Svc
X Code             Description          X Code            Description   X Code                     Description
 ASP, ABSCESS, BIOPSY, INJECTION                   CT BODY / CARDIAC
  5957753   CT ABSCESS PUNCTURE & ASP    5959055    CT CORONARY WO CALCIUM SCORE
  5955165   CT ASPIRATION RENAL PERC     5959063    CT CORONARY W CALCIUM SCORE
  5955173   CT BX ABD OR RETRO MASS      5959004    CT CARDIAC CALCIUM SCORING
  5955181   CT BX BONE DEEP              5959152    CT HEART WWO W GATNG, 3D, EVL
  5955190   CT BX BONE SUPERFICIAL       5959012    CT HEART WWO CONTRAST
  5955203   CT BX LIVER                  5959101    CT CARD STRUCT/CORONARY WO CS
  5955211   CT BX LUNG                   5959110    CT CARD STRUCT/CORONARY W CS
  5955238   CT BX PANCREAS               5959128    CT CARD STRUCTUR W CONGENITAL
  5949319   CT BX PELVIC ORGAN           5955289    CT CHEST W
  5955246   CT BX PROSTATE               5955297    CT CHEST WO
  5955254   CT BX RENAL LEFT             5955301    CT CHEST WWO
  5955262   CT BX RENAL RIGHT            5955335    CT CTA CHEST WWO
  5949408   CT FINE NEEDLE ASPIRATION    5955131    CT ABDOMEN W
            CT HEAD & NECK               5955149    CT ABDOMEN WO
  5955653   CT HEAD W                    5955157    CT ABDOMEN WWO                       CT UPPER EXTREMITY
  5955670   CT HEAD WO                   5955327    CT CTA ABDOMEN WWO          5955513 CT UPPER EXTREMITY BILATERAL
  5955688   CT HEAD WWO                  5955319    CT CTA ABD RUN OFF WWO      5955521 CT UPPER EXTREMITY BILATERAL
  5955343   CT CTA HEAD WWO              5955882    CT PELVIS W                 5955530 CT UPPER EXTREMITY BILATERAL
  5955696   CT IAC W                     5955891    CT PELVIS WO                5955513 CT UPPER EXTREMITY LEFT W
  5955700   CT IAC WO                    5955904    CT PELVIS WWO               5955521 CT UPPER EXTREMITY LEFT WO
  5955718   CT IAC WWO                   5955386    CT CTA PELVIS WWO           5955530 CT UPPER EXTREMITY LEFT WWO
  5955858   CT ORBITS W                  5957605    CT RENAL COLIC PELVIS WO    5955513 CT UPPER EXTREMITY RIGHT W
  5955866   CT ORBITS WO                 5957613    CT RENAL COLIC ABD LTD WO   5955521 CT UPPER EXTREMITY RIGHT WO
  5955874   CT ORBITS WWO                                                       5955530 CT UPPER EXTREMITY RIGHT WWO
  5956013   CT SINUSES W                                                        Please list portions of extremity to be imaged
  5956021   CT SINUSES WO                      CT LOWER EXTREMITY
  5956030   CT SINUSES WWO               5955441 CT LOWER EXTREMITY BILATERAL W
  5955769   CT NECK SOFT TISSE W         5955459 CT LOWER EXTREMITY BILATERAL WO
  5955793   CT NECK SOFT TISSE WO        5955467 CT LOWER EXTREMITY BILATERAL WWO
  5955823   CT NECK SOFT TISSE WWO       5955441 CT LOWER EXTREMITY LEFT W
  5955378   CT CTA NECK WWO              5955459 CT LOWER EXTREMITY LEFT WO
               CT SPINE                  5955467 CT LOWER EXTREMITY LEFT WWO
  5956048   CT SPINE CERVICAL W          5955441 CT LOWER EXTREMITY RIGHT W
  5956056   CT SPINE CERVICAL WO         5955459 CT LOWER EXTREMITY RIGHT WO
  5956064   CT SPINE CERVICAL WWO        5955467 CT LOWER EXTREMITY RIGHT WWO
  5956072   CT SPINE LUMBAR W            Please list portions of extremity to be imaged
  5956081   CT SPINE LUMBAR WO
5956099   CT SPINE LUMBAR WWO
5956102   CT SPINE THORACIC W
5956111   CT SPINE THORACIC WO
5956129   CT SPINE THORACIC WWO
CT   UPPER   EXTREMITY   BILATERAL W
CT   UPPER   EXTREMITY   BILATERAL WO
CT   UPPER   EXTREMITY   BILATERAL WWO
CT   UPPER   EXTREMITY   LEFT W
CT   UPPER   EXTREMITY   LEFT WO
CT   UPPER   EXTREMITY   LEFT WWO
CT   UPPER   EXTREMITY   RIGHT W
CT   UPPER   EXTREMITY   RIGHT WO
CT   UPPER   EXTREMITY   RIGHT WWO
                       OHSU Imaging Services Research Exam Order Form
              Scheduling Phone: (503) 418-0990       Fax to: (503) 494-4621 or 494-5020   Do NOT enter in Epic

              DEPARTMENT: CT SCAN                    INDUSTRIAL ACCOUNT #
                                                     MED. REC. NO.
    ATTENDING PHYSICIAN                              PT. NAME
                                                     BIRTH DATE
    _____________________________________
    Physician Signature                              RESEARCH CONTACT & PHONE #
SIGNS & SYMPTOMS
                                                     REFERRING DEPARTMENT
                                                     ORDERER NAME & PHONE #
REASON FOR EXAM / HISTORY
                                                     Desired machine:
Exam to be read by Radiologist?
DESIRED EXAM DATE & TIME:
     ICD-9: V 72.6 Research patient                     INTERPRETER NEEDED TRANSPORT
      Svc                                      Svc                          Svc
X    Code            Description          X   Code         Description   X Code                  Description
              MRI HEAD & NECK                           MRI BODY               5767041 MR TIBIA FIBULA LT W
    5765692   MR BRAIN W                  X MCCO    MR CARDIAC COMPREHENSIVE   5767059 MR TIBIA FIBULA LT WO
    5765706   MR BRAIN WO                   MCCOS MR CARDIAC COMP W STRESS     5767075 MR TIBIA FIBULA RT W
    5765714   MR BRAIN WWO                  MCCOV MR CARDIAC COMP W FLOW MAP 5767083 MR TIBIA FIBULA RT WO
    5766613   MR MRA HEAD W                                                    5765536 MR ANKLE LT W
                                            MCCOVS MR CARDIAC COMP W FLOW & STRESS
    5766621   MR MRA HEAD WO                MCM-    MR CARD MORPHOLOGY WO CON 5765544 MR ANKLE LT WO
    5766630   MR MRA HEAD WWO               MCM-V MR CARD MORPH WO CONT W FLOW 5765561 MR ANKLE RT W
    5766915   MR SPECTROSCOPY               5765803 MR CHEST W                 5765579 MR ANKLE RT WO
    5767482   MR IAC W                      5765811 MR CHEST WO                5766044 MR FOOT LT W
    5767521   MR IAC WO                     5765820 MR CHEST WWO               5766052 MR FOOT LT WO
    5767563   MR IAC WWO                    5765501 MR ABDOMEN W               5766079 MR FOOT RT W
    5767504   MR ORBITS W                   5765510 MR ABDOMEN WO              5766087 MR FOOT RT WO
    5767547   MR ORBITS WO                  5765528 MR ABDOMEN WWO                   MRI UPPER EXTREMITY
    5767580   MR ORBITS WWO                 5767334 MR MRA ABDOMEN W           5766796 MR SHOULDER LT W
    5766885   MR SINUSES W                  5762766 MR MRA ABDOMEN WWO         5766800 MR SHOULDER LT WO
    5766893   MR SINUSES WO                 5767431 MR MRA PELVIS W            5766826 MR SHOULDER RT W
    5766907   MR SINUSES WWO                5767440 MR MRA PELVIS WO           5766834 MR SHOULDER RT WO
    5767105   MR TMJ BILATERAL              5767709 MR MRA PELVIS WWO          5766419 MR HUMERUS LT W
    5767491   MR NECK W                     5766753 MR PELVIS W                5766427 MR HUMERUS LT WO
    5767539   MR NECK WO                    5766761 MR PELVIS WO               5766443 MR HUMERUS RT W
    5767571   MR NECK WWO                   5766770 MR PELVIS WWO              5766451 MR HUMERUS RT WO
    5766672   MR MRA NECK W                      MRI LOWER EXTREMITY           5765838 MR ELBOW LT W
    5766681   MR MRA NECK WO                5767377 MR MRA LWR EXT W BILAT     5765846 MR ELBOW LT WO
    5766699   MR MRA NECK WWO               5767385 MR MRA LWR EXT WO BILAT    5765862 MR ELBOW RT W
                 MRI SPINE                  5762847 MR MRA LWR EXT WWO BLT     5765871 MR ELBOW RT WO
    5766923   MR SPINE CERVICAL W           5766290 MR HIP LT W                5766109 MR FOREARM LT W
    5766931   MR SPINE CERVICAL WO          5766303 MR HIP LT WO               5766117 MR FOREARM LT WO
    5766940   MR SPINE CERVICAL WWO         5766320 MR HIP RT W                5766133 MR FOREARM RT W
    5766958   MR SPINE LUMBAR W             5766338 MR HIP RT WO               5766141 MR FOREARM RT WO
    5766966   MR SPINE LUMBAR WO            5765986 MR FEMUR LT W              5767113 MR WRIST LT W
    5766974   MR SPINE LUMBAR WWO           5765994 MR FEMUR LT WO             5767121 MR WRIST LT WO
    5766982   MR SPINE THORACIC W           5766010 MR FEMUR RT W              5767148 MR WRIST RT W
    5766991   MR SPINE THORACIC WO          5766028 MR FEMUR RT WO             5767156 MR WRIST RT WO
    5767008   MR SPINE THORACIC WWO         5766478 MR KNEE LT W               5766206 MR HAND LT W
    5767458   MR MRA SPINE CANAL W          5766486 MR KNEE LT WO              5766214 MR HAND LT WO
    5767466   MR MRA SPINE CANAL WO         5766508 MR KNEE RT W               5766231 MR HAND RT W
5766516 MR KNEE RT WO   5766249 MR HAND RT WO
                        OHSU Imaging Services Research Exam Order Form
              Scheduling Phone: (503) 418-0990        Fax to: (503) 494-4621 or 494-5020      Do NOT enter in Epic

              DEPARTMENT: Ultrasound                  INDUSTRIAL ACCOUNT #
                                                      MED. REC. NO.
    ATTENDING PHYSICIAN                               PT. NAME
                                                      BIRTH DATE
    _____________________________________
    Physician Signature                               RESEARCH CONTACT & PHONE #
SIGNS & SYMPTOMS
                                                      REFERRING DEPARTMENT
                                                      ORDERER NAME & PHONE #
REASON FOR EXAM / HISTORY
                                                      Desired machine:
Exam to be read by Radiologist?
DESIRED EXAM DATE & TIME:
     ICD-9: V 72.6 Research patient                      INTERPRETER NEEDED TRANSPORT
      Svc                                       Svc                           Svc
X    Code            Description          X    Code         Description    X Code                     Description
    Abscess, Asp, Biopsy & Needle Loc         6355510 US BREAST LEFT                6355781   US DOP UPPER EXT LT
    6355251US ABS DRAIN BREAST LT             6355528 US BREAST RIGHT               6355790   US DOP UPPER EXT RT
    6355269US ABS DRAIN BREAST RT             6355501 US BREAST BILATERAL           6355773   US DOP UPPER EXT BILAT
    6355277US ABS DRAIN LIVER                 6355579 US CHEST                      6355676   US DOP KIDNEY LT
    6355285US ABS DRAIN RETROPERITNL          6355935 US HEAD                       6355684   US DOP KIDNEY RT
    6355293US ABS DRAIN SUBDIAPHRAGM          6355943 US HERNIA                     6356362   US DOP KIDNEY BILATERAL
    6356354US FINE NEEDLE ASPIRATE            6356001 US KIDNEY LEFT                6356389   US DOP PELVIS COMP
    6355331US ASPIRATION BREAST LT            6356010 US KIDNEY RIGHT               6355749   US DOP PELVIS LTD
    6355340US ASPIRATION BREAST RT            6355994 US KIDNEY COMPLETE            6355731   US DOP PANCREAS
    6355374US ASPIRATION RENAL LT             6356028 US KIDNEY TRANSPLANT          6355757   US DOP SCAN PENILE VESSLS
    6355382US ASPIRATION RENAL RT             6356036 US LIVER                      6355765   US DOP SCROTUM
    6355226US PARACENTESIS                    6356044 US LOWER EXT NON-VAS LT       6355706   US DOP LOWER EXT LT
    6356265US THORACENTESIS ASPIRAT           6356052 US LOWER EXT NON-VAS RT       6355714   US DOP LOWER EXT RT
           US PUNCTURE ASPERATION             6356079 US PANCREAS                   6355692   US DOP LOWER EXT BILAT
  LIST SIGHT:                                 6356087 US PELVIS &                     ULTRASOUND FETAL AND PREGNANT
  6355391 US BIOPSY ABD OR RETRO              6356273 US TRANSVAGINAL                           UTERUS EXAMS
  6355552 US BX BREAST NDLE CORE LT           6356095 US PELVIS COMPLETE            6356338 US AMNEOTIC FLUID INDEX
  6355561 US BX BREAST NDLE CORE RT           6356109 US PELVIS FOLLOW-UP           6355307 US AMNIOCENTESIS
  6355404 US BIOPSY FNA BREAST LT             6356117 US PELVIS LIMITED             6356320 US CERVIX
  6355412 US BIOPSY FNA BREAST RT             6356125 US PHYSIO STDY U EXT ART L    6355587 US CHORIONIC VILLUS SAMPL
  6355421 US BIOPSY LIVER                     6356133 US PHYSIO STDY U EXT ART R    6356346 US DOP MDL CEREBR ARTRY
  6356061 US NEEDLE BX LYMPH NODE             6356184 US PYLORIC STENOSIS           6355722 US DOP OB CORD
  6355439 US BIOPSY MUSCLE                    6356206 US RETROPERITONEAL COMP       6355820 US FETAL NONSTRESS TEST
  6355447 US BIOPSY PANCREAS                  6356214 US RETROPERITONL LT LTD       6355803 US FTL BIPHY PRFL W NSTRS
  6356702 US BX PELVIC ORGAN                  6356222 US RETROPERITONL RT LTD       6355811 US FTL BIPHY PRFL WO NSTR
  6355455 US BIOPSY PROSTATE                  6356192 US RETROPERTNL BILAT LTD      6355854 US GUIDANCE AMNIO
  6355463 US BIOPSY RENAL LT                  6356231 US SCROTUM & CONTENTS         6355595 US GUIDED CORDOCENTESIS
  6355471 US BIOPSY RENAL RT                  6356249 US SOFT TISSUE HEAD & NECK    6355960 US HYSTEROSONO INJ
  6355480 US BIOPSY THYROID                   6356257 US SPINAL CANAL & CONT        6355951 US HYSTEROSONOGRAPHY
  6355838 US FOLLICLE PNCTR 4 RTRV            6356273 US TRANSVAGINAL               6355986 US INFANT HIPS STATIC
  6355862 US GUIDANCE ASPIR OVRY              6356401 US TRANSVAGINAL LTD           6355978 US INFANT HIPS W MVEMNT
X 6355889 US GUIDANCE                           ULTRASOUND EXAMS (DOPPLER)          6345611 US PREG UTRS <14 EA ADD GST
  6355536 US BRST LT PREOP LOCAL              6355650 US DOP HEAD CEREBRL LTD       6345603 US PREG UTRS <14 WKS COMP
  6355544 US BRST RT PREOP LOCAL              6355668 US DOP INTRACRNL ARTRES       6345620 US PREG UTRS FETAL DETAIL
   ULTRASOUND EXAMS (GREY SCALE)              6355633 US DOP CAROTID LEFT           6345638 US PREG UTRS DETAIL ADD GST
  6355234 US ABDOMEN COMPLETE                 6355641 US DOP CAROTID RIGHT          6345662 US PREG UTRS 15+ EA ADD GST
  6355315 US AORTA                            6355625 US DOP CAROTID BILATERAL      6345654 US PREG UTRS 15+ WEEKS
  6355323 US APPENDIX                         6356371 US DOP ABDOMEN COMP           6345689 US PREG UTRS F/U ABNRML SCN
  6355498 US BLADDER                          6355617 US DOP ABDOMEN LTD            6345671 US PREG UTRS FETL DETAL LTD
                                              6355609 US DOP ABD PLV SCRT RTRO      6345646 US PREG UTRS T-VAG REAL TME
                     OHSU Imaging Services Research Exam Order Form
           Scheduling Phone: (503) 418-0990          Fax to: (503) 494-4621 or 494-5020       Do NOT enter in Epic

           DEPARTMENT: CT SCAN                       INDUSTRIAL ACCOUNT #
                                                     MED. REC. NO.
  ATTENDING PHYSICIAN                                PT. NAME
                                                     BIRTH DATE
  _____________________________________
  Physician Signature                                RESEARCH CONTACT & PHONE #
SIGNS & SYMPTOMS
                                                     REFERRING DEPARTMENT
                                                     ORDERER NAME & PHONE #
REASON FOR EXAM / HISTORY
                                                     Desired machine:
Exam to be read by Radiologist?
DESIRED EXAM DATE & TIME:
   ICD-9: V 72.6 Research patient                       INTERPRETER NEEDED TRANSPORT
   Svc                                      Svc                             Svc
X Code            Description            X Code            Description   X Code                        Description
     ABS, ASP, BIOPSY & INJECTIONS        6024513    MYELOGRAPHY ENTIR SPINE        6025170 SPINE CERVICAL 1 VIEW
  6021573 ABS FISTULA / SINUS TRACT       6024521    MYELOGRAPHY LUMBOSACRL         6025188 SPINE CERVICAL 2 VIEWS
  6021719 ARTHROGRAM ANKLE LT             6024530    MYELOGRAPHY THORACIC           6025196 SPINE CERVICAL 3 VIEWS
  6021727 ARTHROGRAM ANKLE RT             6025412    STON REMVL BIL DUCT POSTOP     6025145 SPINE CERVICAL 4 VIEWS
  6021735 ARTHROGRAM ELBOW LT             6025609    URETHROCYSTOG RETROGRDE        6025218 SPINE LUMBOSACRAL 1 VIEW
  6021743 ARTHROGRAM ELBOW RT             6025617    URETHROCYSTOGRAPHY VOID        6025226 SPINE LUMBOSACRAL 2 VIEWS
  6021751 ARTHROGRAM HIP LT               6025650    UROGRPH ANTEGR-VISUL ILEL      6025234 SPINE LUMBOSACRAL 3 VIEWS
  6021760 ARTHROGRAM HIP RT                                                         6025242 SPINE LUMBOSACRAL 4 VIEWS
  6021778 ARTHROGRAM KNEE LT                        NECK, BODY SPINE                6025293 SPINE THORACIC 1 VIEW
  6021786 ARTHROGRAM KNEE RT              6022901    FLUOROSCOPY <=1 HOUR           6025307 SPINE THORACIC 2 VIEWS
  6021794 ARTHROGRAM SHOULDER LT          6025901    SKULL 1 VIEW                   6025323 SPINE THORACIC 3 VIEWS
  6021808 ARTHROGRAM SHOULDER RT          6025030    SKULL 2 VIEWS                  6025331 SPINE THORACIC 4 VIEWS
  6021832 ARTHROGRAM WRIST LT             6025056    SKULL 3 VIEWS                    Other: List Body Part, # of Views &
  6021841 ARTHROGRAM WRIST RT             6024564    NECK SOFT TISSUE               if exam is to be Left, Right or Bilateral
  6021859 ASPIRAT &OR INJ RENAL CYST      6022081    CHEST 1 VIEW                           ex. HIP 2 Views, Right
  6021981 BX BONE NEEDLE DEEP             6022103    CHEST 2 VIEW
  6021999 BX BONE NEEDLE SUPERF           6022138    CHEST PA LAT & APICAL
  6022014 BX LIVER NEEDLE PERCUT          6022146    CHEST PA LAT W FLUORO
  6022022 BX LUNG MEDIASTINM NEEDLE       6022154    CHEST PA LAT W OBLS
  6022031 BX PANCREAS NEEDLE              6022111    CHEST 4 VIEWS
  6022049 BX PLEURA PERCUT NEEDLE         6021506    ABDOMEN 1 VIEW
  6022057 BX RENAL TROCAR NEEDLE          6010351    ABDOMEN 2 VIEWS
  6022065 BX THYROID CORE NEEDLE          6021514    ABDOMEN AP OBLIQ & CONE
  6022171 CHOLANGIOGRAM INTRAOP           6021531    ABDOMEN W DECUB & ERECT
  6022189 CHOLANGIOGRAM POST-OP           6021549    ABDOMEN W DECUBITUS VWS
  6022260 CYSTOGRAM 3 VIEWS               6021557    ABDOMEN W ERECT VWS
  6022278 CYSTOGRAM 4+ VIEWS              6021522    ABD ACUTE 3 VIEW & PA CHST
  6022472 ERCP BILIARY & PANCREATC        6012957    ESOPHAGUS SWALLOWING
  6021310 ERCP BILIARY DUCT ONLY          6022618    ESOPHAGUS
  6021301 ERCP PANCREATIC DUCT ONLY       6012850    PHARYNGL & SPEECH EVAL
  6022685 FALLOP TUBE CTH TRNCRV S&I      6024645    PELVIS 1 VIEW
  6010059 FINE NEEDLE ASPIRATION          6024661    PELVIS 2 VIEWS
  6023517 HYSTEROSALPINGOGRAM             6024670    PELVIS 3 VIEWS
  6023746 INJ SPINE LUMB/SACR CAUDAL      6024688    PELVIS 4+ VIEWS
  6023789 INTRO GI TUBE INCL MX FLUORO    6025544    UGI W AIR W KUB
  6023797 INTRO NASO OR ORO-GI TUBE       6025552    UGI / AIR / KUB / SMAL BOWEL
  6024157 SPINAL TAP & ASPIRATION         6025561    UGI W AIR WO KUB
  6014879 LUMBAR PUNCTURE 4 CHEMO         6025579    UGI W KUB
6024491 MYELOGRAPHY CERVICAL       6025587 UGI / SMALL BOWEL / MX SERIL
6024505 MYELOGRAPHY CERV C1 OR 2   6025595 UGI WO KUB
                       OHSU Imaging Services Research Exam Order Form
            Scheduling Phone: (503)494-8468                Fax to: (503) 494-2879         Do NOT Enter in Epic

              DEPARTMENT: NUCLEAR MEDICINE                 INDUSTRIAL ACCOUNT #
                                                           MED. REC. NO.
   ATTENDING PHYSICIAN                                     PT. NAME
                                                           BIRTH DATE
  _____________________________________
  Physician Signature                                      RESEARCH CONTACT & PHONE #
SIGNS & SYMPTOMS
                                                           REFERRING DEPARTMENT
                                                           ORDERER NAME & PHONE #
REASON FOR EXAM / HISTORY
                                                           Desired machine:
Exam to be read by Radiologist?
DESIRED EXAM DATE & TIME:
ICD-9:      V 72.6 Research patient                            INTERPRETER NEEDED              TRANSPORT
                            Description                                                 Description
                         ENDOCRINE SYSTEM                                    CARDIOVASCULAR SYSTEM
  8210241 ADRENAL CORTEX & OR MEDULA                          8210233   ACUTE VENOUS THROMB IMAGING
  8210802 PARATHYROID IMAGING                                 8210381   CARD BLOOD POOL GATED RVG 1VW
  8210951 THYROID CA METS IMAGING LIMITED                     8210390   CARD BLOOD POOL GATED RVG EXER
  8210969 THYROID CA METS IMAGING WHOLE BODY                  8210403   CARD BLOOD POOL GATED RVG MULT
  8210977 THYROID CA METS UPTAKE                              8210373   CARD BLOOD POOL GTD 1ST PASS
  8210985 THYROID IMAGING ONLY                                8210411   CARD DTRM CENTRL HEMODYN
  8210993 THYROID IMAGING W VASCULAR FLOW                     8210420   CARD SHUNT DETECTION
  8211001 THYROID IMAGING WITH UPTAKE MULTIPLE                8210764   MYOCARD PERFUSION ECT S/RS PHARM
  8211019 THYROID IMAGING WITH UPTAKE SINGLE                  8210772   MYOCARD PERFUSION ECT S/RST EXERCISE
  8211051 THYROID UPTAKE ONLY                                 8210781   MYOCARD PERFUSION PLANAR MULTI REST/STRS
  8211060 THYROID UPTAKE ONLY MULTIPLE                        8210799   MYOCARD PERFUSION PLANAR SINGL REST/STRS
   HEMATOPOIETIC, RETICULOENDOTHELIAL & LYMPHATIC             8210730   MYOCARD PERFUSION SPECT SINGLE
  8210306 BONE MARROW SCAN PARTIAL                            8210748   MYOCARD PERFUSION W EJECT FRACTURE
  8210314 BONE MARROW WHOLE BODY                              8210756   MYOCARD PERFUSION W WALL MOTION
  8207798 LYMPH DRAINAGE SENTINAL NODE                        8211175   VASCULAR FLOW NON CARDIAC
  8210721 LYMPHATCS DRAINAGE MAPING                           8211183   VENOGRAPHY BILATERAL
  8210853 PLASMA VOLUME DILUTION RADPHRM SINGLE SAMPLE        8211191   VENOGRAPHY LEFT
  8210870 RBC VOLUME COUNT SINGLE SAMPLE                      8211205   VENOGRAPHY RIGHT
  8210926 SPLEEN IMAGING W OR WO VASULAR FLOW                                   RESPIRATORY SYSTEM
               GASTROINTESTINAL SYSTEM                        8207216   LUNG PERFUSION & VENTILATN
  8210322 BOWEL IMAGING MECKELS DIVERT                        8210683   LUNG PERFUSION PARTICULATE
  8210489 ESOPHOGEAL MOTILITY                                 8210691   LUNG QUANT DIFFERENTIAL FUNCTION
  8210497 GASTRIC EMPTYING                                    8210705   LUNG VENT ONLY GAS REBREATH
  8210501 GASTROESOPHAGEAL REFLUX                                            BRAIN & NERVOUS SYSTEM
  8210535 GI BLEED, ACUTE BLOOD LOSS                          8210331   BRAIN CEREBRAL BLOOD FLOW
  8210551 HEPATOBIL SYSTM & GALBLADR W FUNCTION               8210349   BRAIN COMPLET STUDY STATIC
  8210560 HEPATOBIL SYSTM & GALBLADR WO FUNCTION              8210357   BRAIN COMPLETE STUDY SPECT
  8210624 LIVER FUNCTION WITH HEPATOBILIARY AGENT IMAGES      8210365   BRAIN VASCULAR FLOW ONLY
  8210632 LIVER IMAGING SPECT ONLY                            8210446   CSF FLOW CISTERNOGRAPHY
  8210641 LIVER SPLEEN IMAGING STATIC                         8210454   CSF LEAK DETECT & LOCATION
  8210659 LIVER SPLEN IMAGING W VASULAR FLOW                  8210462   CSF SHUNT EVALUATION
  8210667 LIVER STATIC WITH VASCULAR FLOW                     8210471   CSF SPECT
  8210675 LIVER WITH VASCULAR FLOW & SPECT                                    GENITOURINARY SYSTEM
  8210811 PERITONEAL-VENOUS SHUNT PATENCY                     8210578   KIDNEY FUNCTION NON-IMAGING RADIOISOTOPIC
  8210888 SALIVARY GLAND IMAGING                              8207950   KIDNEY IMAGING STATIC ONLY
  8210896 SHILLING TEST W INTRINSIC FACTOR                    8210586   KIDNEY IMAGING SPECT
  8210900 SHILLING TEST WO INTRINSIC FACTOR                   8210594   KIDNEY VASCULAR FLOW ONLY
  8210918 SHILLING TEST WWO INTRINSIC FACTOR                  8210608   KIDNEY W FLOW & FUNCTION W PHARM
               MUSCULOSKELETAL SYSTEM                         8207020   KIDNEY W FLOW & FUNCTION W/WO PHARM
  8210250 BONE IMAGING 3 PHASE                                8210616   KIDNEY W FLOW & FUNCTION WO PHARM
  8210268 BONE IMAGING LIMITED AREA                           8210934   TESTICULAR IMG & VASC FLOW
  8210276 BONE IMAGING MULTIPLE AREAS                         8211141   URETERAL REFLUX STUDY
  8210284 BONE IMAGING SPECT                                  8211159   URINARY BLADDER RESIDUAL
  8210292 BONE IMAGING WHOLE BODY                                             MISCELLANEOUS STUDIES
                      THERAPEUTIC                             8210209   ABSCESS LOCAL LTD AREA
  8210861 RADPHARM RX NONTHYROID NONHEMATOLOGIC               8210217   ABSCESS LOCAL TOMO SPECT
  8210942 THERPY CHRONIC LEUKEMA EACH-TX                      8210225   ABSCESS LOCAL WHOLE BODY
  8211027 THYROID RX ABLATN OF GLAND FOR CARCNOMA             8211078   TUMOR LOCAL LIMITED
  8211035 THYROID RX HYPERTHYROID INITIAL WITH EVAL           8211086   TUMOR LOCAL MULTIPLE
  8211043 THYROID RX METS CARCINOMA                           8211094   TUMOR LOCAL SPECT ABDOMEN
  8211400 ZEVALIN TUMOR WHOL BDY INT                          8211108   TUMOR LOCAL SPECT CHEST
8211418   ZEVALIN TUMOR WHOL BDY Y90   8211116   TUMOR LOCAL WHOLE BODY
                                       8211604   NM WHOLE BLOOD VOLUME DETERMINATION (NWBVD)
                OHSU Imaging Services Research Exam Order Form
            Scheduling Phone: (503)494-8468   Fax to: (503) 494-2879   Do NOT Enter in Epic

              DEPARTMENT: NUCLEAR MEDICINE INDUSTRIAL ACCOUNT #
                                           MED. REC. NO.
     ATTENDING PHYSICIAN                   PT. NAME
                                           BIRTH DATE
    _____________________________________
    Physician Signature                       RESEARCH CONTACT & PHONE #
SIGNS & SYMPTOMS
                                              REFERRING DEPARTMENT
                                              ORDERER NAME & PHONE #
REASON FOR EXAM / HISTORY
                                              Desired machine:
Exam to be read by Radiologist?
DESIRED EXAM DATE & TIME:
ICD-9:      V 72.6 Research patient               INTERPRETER NEEDED        TRANSPORT
                         Description                              Description
      Svc                                         Exam
X    Code              Description            X   Code            Description
    NPGN36 PET ALZHEIMERS DIAGNOSIS

    NPG229 PET BRAIN METABOL PRESRG ATTN

    NPBRPF PET BRAIN PERFUSION ATTEN

    NPGLAA PET LIMITED AREA ATTENUATION

    NPGBOAPET SKULL BASE TO THIGH ATTEN

    NPGWBAPET WHOLE BODY ATTENUATION
                     OHSU Imaging Services Research Exam Order Form
            Scheduling Phone: (503) 418-0990     Fax to: (503) 494-4621 or 494-5020   Do NOT enter in Epic

            DEPARTMENT: CT SCAN                  INDUSTRIAL ACCOUNT #
                                                 MED. REC. NO.
  ATTENDING PHYSICIAN                            PT. NAME
                                                 BIRTH DATE
  _____________________________________
  Physician Signature                            RESEARCH CONTACT & PHONE #
SIGNS & SYMPTOMS
                                                 REFERRING DEPARTMENT
                                                 ORDERER NAME & PHONE #
REASON FOR EXAM / HISTORY
                                                 Desired machine:
Exam to be read by Radiologist?
DESIRED EXAM DATE & TIME:
   ICD-9: V 72.6 Research patient                   INTERPRETER NEEDED TRANSPORT
   Svc                                     Svc                          Svc
X Code             Description          X Code         Description   X Code                  Description
  5604001   MA BX PERC NEEDLE CORE BRST L
  5604052   MA BX PERC NEEDLE CORE BRST R
  5604109   MA BX PERC VACUUM/ROT BRST L
  5604150   MA BX PERC VACUUM/ROT BRST R
  5605351   MA DIG MAMMO DIAG LEFT
  5605407   MA DIG MAMMO DIAG RIGHT
  5605504   MA DIG MAMMO DIAGNOSTC BILAT
  5605458   MA DIG MAMMO SCREEN BILAT
  5604257   MA DUCTOGRM-GALACTGRM SNGL LT
  5604303   MA DUCTOGRM-GALACTGRM SNGL RT
  5604354   MA DUCTOGRM-GALCTGRM MULT LT
  5604401   MA DUCTOGRM-GALCTGRM MULT RT
  5604907   MA PREOP PLC LOC WIRE BRST LT
  5604958   MA PREOP PLC LOC WIRE BRST RT
  5605008   MA SURGERY SPECIMEN LEFT
  5605059   MA SURGERY SPECIMEN RIGHT

				
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