Referral Form
Patient Name Indication/Symptoms Date Referring Provider
ID Signature
Provider Phone Provider Fax Circle Musculoskeletal (MSK) Ultrasound Exam
76881
Shoulder with Dynamic Imaging Rotator Cuff Tear Biceps Tendon pathology Shoulder Impingement Tendonitis Bursitis / Effusion
76881
Elbow with Dynamic Imaging Epicondylitis “Tennis Elbow” “Golfer’s Elbow” Bursitis / Effusion
76881
Wrist and Hand with Dynamic Imaging Carpal Tunnel Syndrome / Median Nerve Flexor Tendonitis Extensor Tendonitis De Quiverain’s Disease Trigger Digit
76881
Hip or Hernia Snapping Hip Syndrome Bursitis / Effusion Inguinal Hernia
76881
Knee MCL / LCL Tear Patellar Tendonitis Medial / Lateral Meniscus Tear Baker’s Cysts Bursitis / Effusion
76881
Ankle and Foot Achille’s Tendinopathy Tendon Tears Ligament Tears Plantar Faciitis
76536 Neck – Soft Tissue Ultrasound
76705 Lower Back – Soft Tissue Ultrasound (Spine)
76942 Ultrasound Guided Joint Injection or Aspiration
A+ Mobile Ultrasound Services LLC P.O. Box 13012
Seattle, WA 206.799.3301 phone
206.299.1200 faxwww.APlusUltrasound.com
Vascular Ultrasound Exam
93880 Carotid Duplex
93922 Ankle Brachial Index (ABI)
93923 ABI and Toe Brachial Index (TBI) with PPG
93925 93922
Lower Extremity Arterial Duplex with ABI
93970 Lower Extremity Venous Duplex (DVT)
93970 Upper Extremity Venous Duplex (DVT)93975 Renal Arterial Duplex93975 Mesenteric Arterial Duplex93978 Aorta/iliac Arterial Duplex Abdominal Ultrasound Exam
76700 Complete Abdomen7677051798
Retroperitoneal – KidneysAnd Post Void Bladder
G0389 AAA Screening
Small Parts Ultrasound Exam
76536 Thyroid
76870 Scrotum
93976 Scrotum with Doppler
76882 Superficial Lesion
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