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Doshi Nuclear Pad 1/16/12:Layout 1 1/17/12 1:03 PM Page 1 Nuclear Cardiology • Nuclear Medicine • PET CT 3250 Westchester Ave, Ste LL11 Ph:(718) 823-8616 Fax:(718) 823-8615 Patient’s Name:_______________________________________________________ D.O.B. / Age:________________________ Date:_________________________
Reason for Exam/ICD-9:_________________________________________________ Insurance/Authorization:_____________________________________________
Special Instructions:_____________________________________________________________________________________________________________________
I hereby certify that the exam(s) ordered on this form is/are medical y necessary to manage the care of the patient.
Physician’s Name:_____________________________________________________ Physician’s Signature:_______________________________________________
❑ Nuclear Medicine Myocardial Perfusion Imaging Stress and Resting Studies with Ejection Fraction and Wall ___ Treadmill Exercise - CPT 93015 † ___ Pharmacological - CPT 93015 † ❑ Nuclear Medicine Myocardial Perfusion Imaging Stress or Resting Study with Ejection Fraction and Wall ___ Treadmill Exercise - CPT 93015 † ___ Pharmacological - CPT 93015 † ❑ 730.00 Acute Osteomyelitis❑ 213.9 Benign Neoplasm Bone NOS ❑ Treadmill Stress Test (No Imaging) - CPT 93015 ❑ Other ________________________________________ ❑ 12 Lead ECG - CPT 93000 †❑ MUGA / Ejection Fraction - CPT 78472 † Thyroid Scan and Uptake - CPT 78006 ❑ Thyroid Uptake Only (No Scan) - CPT 78000❑ 241.9 Nontoxic Nodular Goiter NOS Please select the appropriate ICD9 code below ❑ Other ________________________________________ ❑ Renal Scan and Vascular Flow - CPT 78701 ___ with Lasix - ❑ Single Study - CPT 78708___ with Captopril - ❑ Multiple Study - CPT 78709 PET / CT (Available at Stillwell Avenue, Bond Street and Kew Gardens) ❑ Oncology – Whole Body Imaging - CPT 78816 † ❑ Oncology – Limited Area Imaging - CPT 78814 † Oncology – Skull Base to Mid Thigh Imaging - CPT 78815 † Other ________________________________________ Specify Diagnosis _______________________________________________________ ❑ PET Stress (Available at Stillwell Avenue) Specify Diagnosis _____________________________________ ___ Myocardial Stress Perfusion Imaging - CPT 78492 † ___ Single Study at Rest or Stress - CPT 78491 † Specify Diagnosis _____________________________________ ___ Pharmacological Stress - CPT 93015 † Hemangioma (Red blood cell study) - CPT 78206 ❑ Hepatobilary Imaging - CPT 78223 ❑ Neurology – Brain Imaging - CPT 78608 † ❑ Other _____________________________________________ ❑ Other ________________________________________ † Please refer to the Medicare NCD/LCD for this service to ensure compliance with Medicare policy criteria for ordering, performing, documenting,† coding and billing requirements for this service.
Doshi Nuclear Pad 1/16/12:Layout 1 1/17/12 1:03 PM Page 2 PATIENT INFORMATION
PLEASE OBTAIN NECESSARY AUTHORIZATION TO AVOID DELAYS
• Please arrive 25 minutes before your scheduled appointment
• If you must cancel or reschedule, please do so at least 24 hours before your appointment
We will attempt to call all patients 24 hours before your examination. However, if we cannot reach you,
please call the center for specific instructions for your type of exam.
TRAVEL DIRECTIONS
BROOKLYN
BENSONHURST - NUCLEAR: 1783 Stillwell Avenue, Brooklyn, NY 11223
Tel: 718-837-1427 • Fax: 718-232-3497
Car from Belt Parkway: Exit 6, Stillwell Avenue (North) to 80th Street. From Ocean Parkway: Kings Highway, Left on Stillwell to 80th Street.
Subway: D and M to 86th Street & Bay Parkway and any bus North to 79th Street.
Bus: B4 to 80th Street & Stillwell Avenue; B82 or B6 to 80th Street & Bay Parkway & walk to Stillwell Avenue.
MILL BASIN - NUCLEAR: 6301 Mill Lane, Brooklyn, NY 11234
Tel: 718-444-2621 • Fax: 718-444-1056
Car: Take Belt Parkway, Exit 11N (Flatbush Avenue), make Right on Avenue U (Kings Plaza). Make Left on Mill Avenue to corner of Ralph Avenue.
Subway: Q to Avenue U & E. 16th Street.Then B3 Bus east (across street from train station) to Mill Avenue. Make Right.
Bus: Take B3 on Avenue U, Transfer to the B78 at Kings Plaza, to Ralph Avenue. Turn Right on Mill Lane;
B41 to Bergen Beach/Veterans Avenue & 63rd Street. Turn Right on 63rd Street.
DOWNTOWN BROOKLYN: 9 Bond Street, Brooklyn, NY 11201
Tel: 718-222-0202 • Fax: 718-834-1058
Car from Brooklyn: Flatbush Avenue, Left on Livingston Street, Right on Bond Street.
From Manhattan: Brooklyn Bridge, Left on Tillary Street, Right on Flatbush Avenue, Right on Livingston Street, Right on Bond Street.
Subway: B, M, Q or R to Dekalb Avenue. On Flatbush Avenue, walk towards Dekalb Avenue, Right on Fulton Street, Left on Bond Street.
2-3 Train to Hoyt Street. Walk towards Flatbush Avenue, Right on Bond Street.
Bus: B38, B54 Dekalb Avenue & Bond Street. B38, B26, B52 Fulton Street & Bond Street.
B37, B41, B45, B67, B103 Livingston Street & Bond Street.
QUEENS
FLUSHING - NUCLEAR: 147-05 Elm Avenue, Flushing, NY 11355
Tel: 718-888-1568 • Fax: 718-886-1569
Facility is across from Flushing Hospital.
Car: LIE - Exit 24 Kissena Boulevard North, Right on 45th Avenue, Left on 147th Street and Facility is on Right. Parking is available on site.
Subway: #7 to Main Street (Last Stop) - Flushing then take Bus.
Bus: (from Jamaica or Main Street) Q26, Q27 or Q65 to Parsons Boulevard & 45th Avenue. Get off at Flushing Hospital.
JACKSON HEIGHTS: 37-17 76th Street, Jackson Heights, NY 11372
Tel: 718-457-6920 • Fax: 718-457-7684
Car: Northern Blvd., South on 76th Street. Facility is between 37th Avenue & 37th Road. Parking is available on site.
Subway: #7 to 74th Street - Broadway. E, F, G, R & V to 74th Street & Roosevelt Avenue. Walk East 2 blocks & North 2 blocks.
Bus: Q198 or Q47 to 74th Street & 37th Avenue. Q32 to Roosevelt Avenue & 76th Street.
KEW GARDENS / KEW GARDENS - NUCLEAR: 80-02 Kew Gardens Rd., Kew Gardens, NY 11415
Tel: 718-544-2159 • Fax: 718-544-2992
Car: Queens Boulevard, Eastbound to 80th Road. Facility is on Kew Gardens Road & Queens Boulevard. Parking is available on site.
Subway: E or F to Union Turnpike.
Bus: Q37, Q46 or Q74 Union Turnpike Train Station. Q60 to Union Turnpike & Kew Gardens Road. Q10 to Kew Gardens 80th Road,(Last Stop).
LONG ISLAND
HEWLETT- NUCLEAR: 1184 Broadway, Hewlett, NY 11557
Tel: 516-791-9600 • Fax: 516-791-9605
Car from East: Southern State Parkway, Exit 19 South (Peninsula Blvd.) Take Peninsula for 4.4 miles. Make Left at Prospect Avenue (4th light after Sunrise Highway).
Bear Right onto Rockaway Avenue. Bear Right onto Broadway. Facility is 3/4 mile on Right side.
From West (Queens): Southern State Parkway, Exit 13 South (Central Avenue). Continue on Central as it turns into Mill Road. Take Mill to West Broadway (Car Wash on
Right). Make Left on West Broadway. Make 2nd Right (Burger King). Bear Right onto Broadway. Facility is 3/4 miles on Right. Parking is available on site. Please askor see receptionist in office for parking instructions.
LIRR: Hewlett Station, take bus MTA32 or walk East on Franklin Avenue, South on Broadway.
Bus: MTA32.
MANHATTAN
WASHINGTON HEIGHTS: 4120 Broadway (174th Street) New York, NY 10033
Tel: 212-543-4141 • Fax: 212-543-9555
Car from the Harlem River Drive: Take the W. 177th Street Exit. Go to Broadway and drive South.
From the Henry Hudson: Take Exit 14 to Riverside Drive to W. 177th Street. Go to Broadway and drive South.
Subway: Take the #1 to W. 168th Street. Take D to W.145th Street. Transfer to the A to W. 175th Street.
Bus: Take the #5, 7, 100 to W. 174th Street & Broadway.
BRONX
PELHAM BAY - NUCLEAR: 3250 Westchester Avenue, Suite LL11, Bronx, NY 10461
Tel: 718-823-8616 • Fax: 718-823-8615
Car: From Northern Bronx, Westchester & Connecticut: I-95 South to Exit 8A (Westchester Avenue). Right at light. Right onto Westchester Avenue. Left into parking lot
From Western Bronx, Manhattan & New Jersey: Cross Bronx Expressway to I-95 South. Follow Above directions from Northern Bronx. Parking is available on site.
Subway: #6 Line to Pelham Bay Station.
Bus: #5, #12, #14, #29, QBX1, Westchester Avenue Bee Line #45, Co-op City shuttles and Manhattan Express Bus line to Pelham Bay Station. Walk 100 yards under
elevated subway to Pelham Bay Professional Center.
FORDHAM: 410 East 189th Street, Bronx, NY 10458
Tel: 718-733-6826 • Fax: 718-364-0938
Car from Queens, Long Island or Manhattan: Cross Bronx Expressway (Westbound) to Third Avenue, left on 178th Street, right on Webster Avenue & right on 189th
Street. (Eastbound to Webster Avenue, left on Webster & right on 189th). Parking is available on site.
Metro North Railroad: To Fordham Road Station.
Subway: B, D & #4. Get off at Fordham Road Station and go towards Webster Avenue
Bus: #9, #22, #12 exit at Fordham Road & Park Avenue. #41, exit at E.Fordham Road & Webster Avenue.

Source: http://www.mrixray.us/referral/Doshi_Nuclear_Referrar.pdf