MDS MI ORDERS

MDS MICHIGAN SECURED ONLINE ORDER FORM

4479 Pontiac Lake Rd. Ste 1D Waterford Michigan 48328
Nature of Order*

ROUTINE ORDER (24 Hours turnaround time)LIFE THREATNING STAT (Only for LIFE THREATNING SYMPTOMS OR CIRCUMSTANCES. 4 Hours turnaround time. Signed copy of the order indicating "STAT" is mandatory). Please note: NO STAT EKG service.
Organization Name:*
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Phone Number:*
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Fax Number:*
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Email address:
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Patient Name:*

First NameMiddle NameLast Name
Date of Birth:*

MonthDayYear
Gender:*
SSN Number*
Room Number and Bed Number:*
Please specify building, unit, room and bed numbers
Address/Contact Information/Telephone Number:
Please fill out if home patient.
Special Instructions:
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Primary Insurance Provider:*
Insurance ID/Authorization Number:*
Ordering Physician/NP:*

First NameLast Name
Date of Service:*

MonthDayYear
PLEASE SELECT PROCEDURE(S):*
Other Procedure(s): **PLEASE SELECT "OTHER PROCEDURE" FROM THE ABOVE DROP DOWN MENU**
Please specify in detail
REASON FOR SERVICE: PLEASE LIST THE PATIENT’S SPECIFIC SIGNS & SYMPTOMS – “R/O IS NOT ACCEPTABLE" *
Nurse Name*

First NameLast Name
Nurse Initials*

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Patient Document Upload:

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Please upload Facesheet/Orders/Additional Documents Cancelof
We are required by State and Federal agencies to maintain in our files a signed order (written confirmation of your verbal order), that specifies the reason of the exam is required, the area of the body to be exposed, and the number of views needed. We are required to maintain your statement concerning the condition of the patient which indicates why portable diagnostic services are required.
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MDS MICHIGAN SECURED ONLINE ORDER FORM