Imaging Referral Form

Fill it in on screen, print it, and fax to 727.216.4789.

Complete this form on any device — nothing is sent over the internet, it stays in your browser until you print. One call reaches every location: 727.787.6900. Prefer paper? Download the printable pad (PDF).

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Which center offers what

Every location is ACR accredited. High Field MRI and X-Ray are available at all nine.

Location	High Field MRI	Arthrograms	Wide Open Bore MRI	High Field Open MRI	CT Scan	X-Ray	Ultrasound	Echo Cardiogram	3D Mammography	Dexa-Bone Density
Palm Harbor MRI 32615 US Hwy 19 N, Palm Harbor 34684 Phone: 727.787.6900 · Fax: 727.787.1892	✓	✓	✓	✓	✓	✓	✓	✓	✓	✓
Palm Harbor MRI – Wesley Chapel 27662 Cashford Circle, Wesley Chapel 33544 Phone: 813.815.8010 · Fax: 813.762.1405	✓	—	✓	—	✓	✓	✓	✓	—	—
Highland MRI 2946 Lakeland Highlands Rd, Lakeland 33803 Phone: 863.510.5944 · Fax: 863.510.5939	✓	✓	✓	✓	✓	✓	✓	—	—	—
Winter Haven MRI 409 E Central Ave, Winter Haven 33880 Phone: 863.294.0999 · Fax: 863.294.0010	✓	—	—	—	✓	✓	✓	—	✓	✓
Brandon MRI 403 S Kings Ave, Suite 200, Brandon 33511 Phone: 813.210.8995 · Fax: 813.409.2914	✓	✓	✓	—	✓	✓	✓	✓	✓	✓
Sarasota MRI 2 N Tuttle Ave, Sarasota 34237 Phone: 941.951.1888 · Fax: 941.951.1910	✓	✓	—	✓	✓	✓	✓	✓	—	—
Bradenton MRI 5817 21st Ave W, Suite B, Bradenton 34209 Phone: 941.567.4039 · Fax: 941.567.4041	✓	—	—	—	—	✓	—	—	—	—
Venice MRI 1370 E Venice Ave, Suite 101, Venice 34285 Phone: 941.484.6500 · Fax: 941.484.6556	✓	✓	✓	—	✓	✓	✓	—	—	—
Venice MRI – Port Charlotte 21186 Olean Blvd, Port Charlotte 33952 Phone: 941.289.0705 · Fax: 941.237.5903	✓	—	✓	—	✓	✓	✓	—	—	—

Diagnostic codes (ICD-10)

The codes we are asked for most often. Confirm against your own coding before submitting.

Spine

M54.12: Radic Cervical Region
M54.14: Radic Thoracic Region
M54.16: Radic Lumbar Region
M54.2: Cervical
M54.6: Thoracic
M54.50: Lumbar
S13.4XXa: Cervical Sprain (initial)
S23.3XXa: Thoracic Sprain (initial)
S33.5XXa: Lumbar Sprain (initial)
M48.02: Cervical Stenosis
M48.04: Thoracic Stenosis
M48.06: Lumbar Stenosis
M54.30: Sciatica

Upper extremity

M25.519: Shoulder (unspec)
M25.511: Shoulder (R)
M25.512: Shoulder (L)
M25.529: Elbow (unspec)
M25.521: Elbow (R)
M25.522: Elbow (L)
M25.539: Wrist (unspec)
M25.531: Wrist (R)
M25.532: Wrist (L)
M79.643: Hand (unspec)
M79.641: Hand (R)
M79.642: Hand (L)
M79.603: Arm (unspec)
M79.601: Arm (R)
M79.602: Arm (L)
M79.609: Limb (unspec)

Lower extremity

M25.559: Hip (unspec)
M25.551: Hip (R)
M25.552: Hip (L)
M25.569: Knee (unspec)
M25.561: Knee (R)
M25.562: Knee (L)
M79.673: Foot (unspec)
M79.671: Foot (R)
M79.671: Foot (L) — see flags
M25.579: Ankle (unspec)
M25.571: Ankle (R)
M25.572: Ankle (L)
M79.606: Leg (unspec)
M79.604: Leg (R)
M79.605: Leg (L)

Other pain

R10.9: Abdominal
R10.10: Abd (Upper)
R10.30: Abd (Lower)
R10.2: Pelvic
R07.9: Chest

Other codes

R94.5: Abn Result Liver (LFT)
J20.0: Bronchitis Acute
N20.0: Calculus Kidney
J44.9: COPD
R05: Cough
M23.8x9: Derangement Knee
M24.819: Derangement Shoulder
M51.26: Disc Displace Lumbar
R42: Dizziness/Giddiness
I84.409: DVT Lower Ext — see flags
R51.9: Headache
R31.9: Hematuria (unspec)
I10: Hypertension Primary
G47.0: Insomnia
N63.0: Lump Breast
R22.0: Lump/Swelling Head
R22.1: Lump/Swelling Neck
R22.2: Lump/Swelling Trunk
G47.419: Narcolepsy w/o Cata
M19.90: OA (unspec site)
M17.9: OA Knee (unspec)
M19.019: OA Shoulder (unspec)
I65.29: Occl/Stenosis Carotid
M06.9: Rheumatoid Arthritis
R06.02: Shortness of Breath
J01.90: Sinusitis Acute
J32.9: Sinusitis Chronic
R55: Syncope / Collapse
S83.205: Tear Meniscus Cur (A initial / D subsequent)
M75.100: Tear/Rupt Shoulder
G45.9: Tran Cerebral Isch
M26.60: TMJ (unspec)

Screening

Z13.820: Osteoporosis
Z02.1: Pre-Employment
Z00.00: General Adult
Z12.31: Mammography
Z13.9: Unspecified

Codes reproduced from the MRI Associates 2026 script pad · Updated 2026-09-05