Ultrasound referral form 2026

1. Click ‘Get Form’ to open the ultrasound referral form in the editor.
2. Begin by entering the 'Date Ordered' at the top of the form. This helps track when the referral was made.
3. In section A, fill in the patient's 'NAME', 'DOB', and 'FHCP #' for identification purposes. Also, provide details for the referring physician and their provider number.
4. Move to section B to select the 'ULTRASOUND EXAM REQUESTED'. Choose from options like 'Abdomen Complete' or 'Pelvic', and ensure you note down the corresponding CPT code.
5. Indicate the number of films required in section B as well.
6. In section C, enter a relevant 'Diagnostic Code' that corresponds with the patient's condition.
7. Section D requires a detailed written diagnosis and reason for request. If applicable, attach any previous diagnostic reports.
8. Finally, complete section E by filling in the appointment date and time. Remember that sections C and D must be completed for scheduling.

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