Forms & Instructions

Please select a form that best suits your needs.

Order Forms

Use this form if you are a physician’s office scheduling an exam for a patient .

Use this form if the patient has had an incomplete colonoscopy.

Waivers for Screening

Please complete this screening waiver if you are to undergo a Virtual Colonscopy test at BWH. Form also includes explanation, costs, and insurance information.

For Medicare patients, please use this Advance Beneficiary Notice.

Indications for Diagnostic

Diagnostic colonography does not have a CPT code and is not covered by most insurers. However, if appropriate indications are present for a CT abd/pelv/3D performed, a diagnostic exam may be billed under the CPT codes for these exams. Below are acceptable indications for CT abd/pel/3D appropriate for a scan of the colorectal area.

Common Symptoms Used:

  Constipation
  abdominal pain
  gastrointestinal bleeding
  abnormal weight loss
  benign neoplasms
  primary or secondary malignant neoplasms
  onset of new symptoms involving digestive system

For a printable list of these symptoms with description, please view this form.

Prep Instructions

Having a Virtual Colonoscopy done? This preparation checklist will help you prepare for your procedure.

Medicare may not cover the costs of your screening procedure. Please review and complete the Advance Beneficiary Notice form before your appointment.