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


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

Emergency Radiology
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


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