Breast Imaging Outpatient Order Form

QUSTIONS:
847.535.6350
Breast Imaging
Outpatient Order Form
SCHEDULING:
847.535.8000 TEL
847.535.8001 FAX
nlfh.nm.org
Thank you for referring your patient to Northwestern Lake Forest Hospital. Please complete all fields to expedite your request.
Orders submitted with complete schedule and pre-certification information will be processed by the Scheduling Department within 72 hours.
PATIENT INFORMATION
Last Name
PHYSICIAN INFORMATION
First Name
Date of Birth
Primary Phone Number
Pre-Certification Required:  No  Yes:
Pre-Cert/Auth #
Insurance Name
Referring Practitioner Last Name
First Name
NPI #
Practitioner’s Phone Number
Practitioner’s Fax Number
Practitioner’s Signature
Date
Pre-Cert/Auth Effective Dates
REASON FOR TEST
ORDER/RESULTS continued
REASON FOR THE TEST MUST BE GIVEN
BREAST MRI
Copies of all mammography, breast ultrasound, MRI and pathology reports performed
anywhere other than Northwestern Lake Forest Hospital facilities are required.
ICD Codes (s): _______________, _______________, _______________
Reason/Diagnosis:
 Breast MRI Bilateral W/WO
Note: MRIs w/wo contrast require a Creatinine & GFR (within 6 weeks) for the
following: age of 65 years and older, kidney disease, IDDM, severe liver disease and/or
lupus
 Order Creatinine/GFR
 Results attached
 N/A
 Breast MRI Silicone Implant Eval WO ……………………….……… R L B
MAMMOGRAPHY
ORDER/RESULTS
Results will be sent to fax number on file unless indicated above.
Orders are valid for 6 months.
 Interventional
 Stereotactic
 Ultrasound Guided Breast biopsy
 MRI Guided Breast Biopsy
 Cyst Aspiration
 Ductogram
 Other
____________________________________________________
 Osteoporosis Screening
 DEXA
 Quantitative CT
 Vertebral FX Assessment
FORM # 5030533
 Screening Mammogram
Asymptomatic patients only
 With Tomography
 Baseline Exam
 Asymptomatic patients/routine mammogram exam
 Family history, no clinical concerns
 Previous benign biopsy, no clinical concerns
 Augmentation implants, no clinical concerns
WHEN MEDICALLY NECESSARY
 Breast Ultrasound may be performed
 Diagnostic Mammogram may be performed
 Diagnostic Mammogram and possible Breast Ultrasound
if indicated
 With Tomography
 Abnormal Mammogram
 Short interval Follow-up
 Palpable Lump or Thickening
 Previous mastectomy
 Nipple Discharge
 Other ___________________________________________
 Ultrasound imaging needed as part of diagnostic exam
 Abnormal Mammogram
 Short interval Follow-up
 Palpable Lump or Thickening
 Previous mastectomy
 Nipple Discharge
 Other ___________________________________________
04/15
Diagnostic Imaging Services
Lake Forest Hospital
660 N. Westmoreland Road
Lake Forest, IL 60045
Gurnee – Brookside
36100 N. Brookside Drive
Suite LL-10
Gurnee, IL 60031
Grayslake
1475 E. Belvidere Road
(Rte. 120)
Grayslake, IL 60030
Gurnee – Tower Court
25 Tower Court
Suite A
Gurnee, IL 60031
Glenview
Outpatient Center
2701 Patriot Boulevard
(Willow Road and Patriot
Boulevard)
Glenview, IL 60026
Libertyville
1800 Hollister Drive
Suite G-10
Libertyville, IL 60048