Office: 535 Ocean Avenue, Portland, Maine 04103     Phone: (207) 518-6000     Fax: (207) 518-6001

Ultrasound Form

Download Ultrasound Policy Form (PDF)

1.) Obstetrical Ultrasounds:
When an ultrasound is performed multiple procedures may actually be done during one visit and more than one charge may be generated. Additional procedures may be performed according to each clinical situation. Please be aware that even when a procedure is medically appropriate and necessary, this does not guarantee insurance coverage.

It may also be necessary to perform an internal ultrasound to properly assess a clinical concern; this cannot always be determined at the time the ultrasound is ordered.

2.) Pelvic Ultrasounds (not pregnant):
A complete pelvic ultrasound involves both a “trans-abdominal” (over the belly) and a “trans-vaginal” (internal) scan. They are both charged separately. As with OB scans, it is possible that based upon the findings of the initial scans, other procedures may be clinically indicated.

It is possible to have a trans-abdominal or trans-vaginal scan only but this is in very specific situations and by the order of the provider.

In recent years, obstetrical ultrasound imaging has improved dramatically, and it is commonly thought that all birth defects maybe detected. Limitations of sonographic imaging must be taken into consideration.

Ultrasound is able to detect many but not all defects. The most common types of problems that are not seen are gastrointestinal (stomach & intestines) and cardiac (heart). Factors contributing to lack of visualization include fetal age, amount of amniotic fluid, mother’s size and fetal position.

After reading this statement, I understand that the sonographic examination cannot ensure a healthy, normal infant. I also understand that the information from my ultrasound and pregnancy may be used as part of my quality assurance or research. My identity and my baby’s identity will be kept confidential in any report or publication resulting from these activities.

Please be aware that you may be charged for multiple ultrasounds on one day due to the types of ultrasounds that are done to achieve the pictures that the Provider requires.

Again, even if a procedure is medically appropriate this does not always guarantee insurance coverage.
I have read and understand the above policy. By signing this I agree with WWCC Ultrasound Procedures.

Download Ultrasound Policy Form (PDF)