126054

Central Scheduling: 860-289-3375
Fax: 860-290-4108
isit our website at effersonradiology
jeffersonradiology .com
.com for more information.
REQUISITION FOR BONE MINERAL DENSITY MEASUREMENTS
& VERTEBRAL FRACTURE ASSESSMENT
Hartford
Glastonbury*
West Harfford*
Wethersfield*
*Vertebral Fracture Assessment (VFA) available in these offices only.
This form must be received by Jefferson Radiology prior to appointment.
If last bone density study was less than 2 years, please indicate reason for repeat study: Choose studies:
Bone Density
Vertebral Fracture Assessment
ONLY CODES LISTED BELOW ARE CONSIDERED PAYABLE BY MEDICARE (see reverse for indications for VFA)
Risk factors documented in the patient’s medical record:
ICD-9 Code
Estrogen deficiency and clinical risk for osteoporosis: Premature menopause (before age 40 years) Other ovarian failure (delayed menarche, ovarian hypofunction, primary ovarian failure) Symptomatic menopausal states (flushing, sleeplessness, headache, lack of concentration) X-ray report of vertebral osteopenia, osteoporosis, or vertebral fracture (submit report with requisition): Vertebral fracture without mention of spinal cord injury (specify level of fracture ) Vertebral fracture with spinal cord injury (specify level of fracture ) Monitoring the therapeutic response to or efficacy of an FDA approved drug therapy: Fosamax, Didronel, Evista, Estrogen, Calcitonin (circle one) Steroids (minimum 7.5 mg Prednisone or 30 mg Cortisone for at least 3 months)Heparin Drugs causing adverse effects in therapeutic use (adrenal cortical steroids) Screening for osteoporosis (non Medicare patients ONLY)
SIgnature of Referring M.D. (Required)
DIRECTIONS
From Simsbury, follow Route 10 South to light. Turn L into Avon Wellness Center.
From I-84 East or West, take Exit 39. Go straight onto Route 4 W to intersection
Avon, CT 06001
of Routes 10/202. Turn R on Route 10N to Route 44. Turn L on Route 44 W. TurnR on Route 10/202 N. Go 1/4 mile and turn R into parking lot at light (AvonWellness Center).
From I-91 North or South, take exit 29A. Go around rotary and take Hudson Street
Hartford, CT 06106
to the end. Turn R on Jefferson Street. Turn L on Seymour Street. From I-84 West,
take exit 54. Turn L on Columbus Blvd. Follow blue H (hospital) sign. Turn L on
Seymour Street. From 1-84 East, take Exit 48A/48B (Asylum Street/Capitol Avenue).
Turn L on Capitol Avenue. Turn R on Washington Street. Go through light at inter-
section of Washington and Jefferson. At next light turn L onto Seymour Street.
From Route 2 West, take Exit 8. Turn R on Oak Street, R on Hebron Avenue, R on
Oakwood Drive (entrance on L). From Route 3 E and I-84 E or W to Route 2 East,
Glastonbury, CT 06033
take Exit 8 off of Route 2. Turn L on Hebron Avenue, then R on Oakwood Drive(entrance on L).
From I-84 East or West, take Exit 43. Turn R on Park Road, then immediate L
West Hartford, CT 06107
onto Trout Brook Dirve. Turn L on Farmington Avenue (office on L). From Route 44
East, turn right on North Main Street, then L onto Farmington Avenue (office on R).
From I-9I North, take Exit 24. Turn R on Silas Deane Highway (office on R). From
I-9I South, take Exit 24. Turn L onto Silas Deane Highway (office on R) From
Wethersfield, CT 06109
Route 3 West, turn L on Silas Deane Highway (Route 99). Office is about 1 mile
on L. From Route 175 E (Cedar Street in Wethersfield), turn R on Silas Deane
Highway (office about 3 1/2 miles on L).
PATIENT INSTRUCTIONS FOR BONE DENSITOMETRY
This examination should not be done within 2 weeks of a nuclear medicine procedure, within 1 week of anycontrast study or 48 hours post barium study. Patients wearing clothing without metal (i.e. zippers, snaps,underwire bras, etc.) can have exam without changing out of street clothes. Do not take calcium supplementsor osteoporosis medications for 24 hours prior to examination.
Vertebral fracture assessment indications listed below were taken from the International Society of Clinical Densitometry.
Indications for first time VFA
• Age (Women over 65 and men over 70)• Known height loss of 1.5” (4 cm) • History of vertebral fracture with no documentation• Nonvertebral fracture after age 45 • BMD evidence of osteoporosis at hip or spine Indications for follow up VFA
• Patients with high risk of vertebral fractures (such as those with previous vertebral fractures or known osteoporosis).
• Clearly documented height loss of at least 2 cm (3/4”).
• Follow-up VFA may be considered at the time of follow-up BMD in patients who are at high risk for vertebral fractures to assess the effect of therapy for osteoporosis given for at least 1 year.

Source: http://cmitjxr.vasculardomain.com/images/uploaded/JeffRad/BoneDensityReq%206-5-08.pdf