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Cardiovascular Ultrasound Services, Inc.

Patient Referral and Information Sheet

Patient Name:
Referring Physician:
Date:
Time:
Indication / Symptoms:
Primary Insurance:
Echocardiography
2-Dimensional [93307]
Color [93320]
Doppler [93325]
Carotid Doppler Exam [93880]
Extremity Arterial Exam
Upper Extremity Duplex [93930]
Lower Extremity Duplex [93925]
Segmental Pressures Limited [93922]
Segmental Pressures Complete [93923]
Venous Duplex/Color [xxxx]
Upper Extremity [93970]
Upper Extremity Limited [93971]
Lower Extremity [93970]
Lower Extremity Limited [93971]
Abdominal Exams
AAA [93978]
Renal Vascular [93975]
Mesenteric Vascular [93976]
Other
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Cardiovascular Ultrasound Services, Inc.
Phone:(614) 870-3301
Fax:(614) 870-1121
 
New Location
5212 West Broad Street
Columbus, Ohio
43228

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