Massachusetts health plans accept a standard one-page authorization form for non-obstetric ultrasound studies. Ordering clinicians and imaging facilities meet it when a plan or its radiology benefit manager requires approval before an ultrasound. Developed by the Massachusetts Collaborative and required under Division of Insurance Bulletin 2017-04, it asks for the exam codes, the reason for the study, prior imaging and whether symptoms have changed since.
The ordering physician's office or the facility completes the form; it asks who is making the request (ordering physician, facility or other) and the signer's title, such as MD, RN, LPN, PA or NP. The patient completes nothing.
Download the current version from the source each time; forms change without notice.
Non-OB Ultrasound Authorization Form
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The form asks who is making the request: the ordering physician, the facility or someone else. The signer prints their name and checks a title, MD, RN, LPN, PA, NP or other, then signs and dates it, so clinical staff can submit it for the ordering physician or facility.
It asks whether there was prior imaging for the condition (ultrasound, CT, CTA, MRI, MRA or x-ray), when the most recent study was done, from under a week to over a year ago, and whether new or worsening signs, symptoms or exam findings have appeared since that study.