Shady Grove Radiology Appointment Form (Page 2 of 2) in pdf

Exam Preparations

Participating Insurances

Shady Grove Radiology participates with most insurance companies. If

Ultrasound-Abdomen, Aorta or Gallbladder

you do not see your company listed, please contact us for assistance.

Nothing to eat, drink smoke or chew for at least 6 hours

Adventist Healthnet

Informed

prior to appointment.

Aetna HMO / US Healthcare

Injured Workers Insurance Fund

Aetna PPO

John Hopkins Uniformed Srvcs

Germantown

Aetna-Medicare

Kaiser Permanente

Ultrasound-Pelvic/Obstetrical

19731 Germantown

Alliance PPO

MAMSI

Suite 102

One and one-half hours prior to appointment, drink 32 oz.

Americhoice

Mailhandlers/CAN

Germantown, MD 20874

of water, to be finished at least one hour prior to the

(301) 444-8700 Fax (301) 444-8710

Amerigroup (formerly Americaid)

MD Health Insurance Plan

Anthem (Trigon)

Maryland Physicians MCO

appointment. DO NOT EMPTY BLADDER.

Beechstreet

MDIPA/ Optimum Choice *Limited procedures

Medical Plaza II

9711 Medical Center Drive

Blue Shield of MD PPO

Med-Eval

Mammogram

Suite 310

Blue Shield NASCO Acct

Medical Assistance/Medicaid of MD

Rockville, MD 20850

Do not use deodorant, perfume or powder on the under

Blue Shield State of MD

Medicare

(301) 762-2550 Fax (301) 762-5344

arms or breast area the day of the exam. BRING PREVIOUS

Blue Shield Natl Acct

Medicare/Railroad Retirement

Blue Shield of Nat’l Capital Area

Medicare United Mineworkers

MAMMOGRAMS FOR COMPARISON.

Shady Grove Medical Village

Blue Choice

Medlink (WC and PPO)

9850 Key West Ave.

Suite 100

Bravo

MHIP (MD Health Insurance Plan)

DX Scan-Bone Density

Rockville, MD 20850

Capp Care

Multiplan

(240) 864-1100 Fax (240) 864-1125

Do not take calcium 24 hours prior to exam.

Care First

NCAS

Champus/Tricare

NCPPO

Medical Plaza II, High Tech

Cigna HMO, POS, Network

NPPPN

9711 Medical Center Drive

Routine Diagnostic X-ray

Cigna PPO

OCI Direct

Suite 101

There is no preparation and appointment is not needed.

Commercial Care Network (CCN)

One Health Plan

Rockville, MD 20850

(301) 762-8155 Fax (301) 762-4402

Coventry Health Care of Del, PPO

PHCS-Private Health Care Systems

Diagnostic Radiology Network

Preferred Health Network

Montgomery Village Professional Center

Elder Health

Primary Care Mid-Atlantic

19241 Montgomery Village

Evercare

Priority Partners MCO

Suite E-13

Expert Medical Opinions

Pro America

Montgomery Village, MD 20886

(301) 948-6414 Fax (301) 590-8964

Fidelity PMG Network

Protocol

First Health

Raytel (WC)

Edmonston Crossing

Freestate

Take Care

101 W. Edmonston Drive

GEHA

Travelers

Rockville, MD 20852

Great West/One Health

US Healthcare/ Aetna HMO

(301) 762-1818 Fax (301) 762-5803

Healthcare 2000

United Health Care

Healthkeepers

United Healthcare of the Mid-Atlantic

HUMANA (Choice Care Only)

Exam Preparations

BUN/Creatinine Policy

CT/CTA Scan-brain, spine, chest or extremities

If your physician has ordered IV contrast and you are: over 60 years of

Nothing to eat drink, smoke, or chew for at least 4 hours

age, are diabetic, have a history of kidney disease, kidney failure, or

prior to the examination. However, medications may be

have one kidney, you will need to have BUN and Creatinine (kidney

taken with a small amount of clear liquid. For IV Contrast,

function) blood work within 30 days of your exam. The results will

please refer to BUN/Creatinine Policy.

need to be sent, faxed or brought to our office at the time of the exam.

This information will be needed before we can perform the exam

CT/CTA Scan-abdomen and/or pelvis study

Nothing to eat drink, smoke, or chew for at least 4 hours

prior to the examination. Patients, however, may consume

clear liquids (broth, water, consomme) up to 4 hours prior

Insurance Requirements

to studt. Please pick up instructions and oral contrast at our

CT Scan offices 24 hours prior to your appointment. For IV

Please call Shady Grove Radiology Centralized Scheduling at (301) 590-8999

Contrast, please refer to BUN/Creatinine Policy.

to schedule your appointment. We ask that you have your insurance card and

this order when you call. The scheduling representative will inform you if your

MRI (Magnetic Resonance Imaging)

insurance requires a pre-certification/authorization. You will need the certification/

For non-IV Contrast studies, there is no preparation. For IV

authorization number prior to scheduling your appointment.

contrast (Gadolinium) please, refer to the BUN/Creatinine

1. Shady Grove Radiology has pre-certification/authorization specialists that

Policy. There are patients who cannot be examined with this

can work with you and your physicians office as needed.

scanner. You may not have this examination if you have any

2. Most insurance companies require your physician office to obtain the

of the following: cerebral aneurysm clips, cerebral bypass

pre-certification/authorization numbers.

surgical clips, middle ear prostheses, cardiac pacemaker,

3. Contact your physician’s office or insurance company for the

neurostimulator, or if you have a history of metallic foreign

pre-certification/authorization numbers.

bodies. For head studies, do not wear any eye makeup or

Pre-Authorization #:___________________________________________________

hair spray. For all studies, do not wear any jewelry.

Scheduling (301) 590-8999

Name of Ins. Contact:_________________________________ Extension:________

Nuclear Medicine

Preparation vary. Please contact (240) 864-1100 for exam

If you are informed that no pre-certification is necessary, please document

preps.

person’s name, phone number and extension.

Shady Grove Radiology Appointment Form Page 2

Related Articles

Related forms

Related Categories