REQUEST FOR PORTABLE DIAGNOSTIC

ULTRASOUND

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VASCULAR

CARDIOVASCULAR

CARDIAC STUDIES

RADIOLOGY

(signs/symptoms)
 

Statement concerning the condition of the patient to warrant portable X-ray service: The exam(s) that I ordered for this patient were medically indicated and necessary for the treatment and/or diagnosis. The patient would find it physically and/or psychologically taxing to receive Portable X-ray service in a place other than the exam site due to the reason(s) documented on this form. Furthermore, it would be detrimental to the patient’s physical and/or mental condition to be transported for this procedure. I understand that this information may be used by (CMS) to scout the determination of medical necessity of portable X-ray services and that I have personal knowledge of the patient’s condition at the time of service. CFR 410.32 (a): Test must be ordered by the physician who is treating the beneficiary and will use the results in the management of the beneficiary’s specific medical problem.