LAC+USC Department of Radiology
After-hours Coverage
Statement of Services Rendered

     
 


First Name:   Last Name:  
       
       
Select Date of Service:   Email:  

  		     
     
       
       
Emergency Radiology
in-house:
Emergency Radiology/Teleradiology:
       
   
Were you called?
 
       
  (Incomplete information about teleradiology will jeopardize entire payment for entire coverage)
     
What time and how many times?  
Name of referring physician(s):  
Patient Name:  
Patient MR #(s):  
       
       
MRI In-House:
       
CT Body:
       
CT Neuro:
       
       
Please select:      
Holiday Weekend
 
Call Commitment,
i.e.: No extra pay
 
       
       
Comments:  
   
       
       
   
 
 
 

Forms Must be filled out completely and submitted no later than the second day of the month following the month in which the service was performed