CARDIO/PULM/VASC REFERRAL FORM

Transcription

1 Vascular Lab (517) Fax: (517) CARDIO/PULM/VASC REFERRAL FORM Cardio/Pulm Referrals (517) Fax: (517) Mon-Fri, 8 a.m. - 5 p.m. to schedule all exams If exam needs to be cancelled, please notify department 24 hours in advance. Last ame: First ame: Date of Birth: Male Female Appointment Date: Middle Initial: Appointment Time: Secondary: Primary Insurance: Authorization: Cardiovascular Diagnosis/Symptoms: Pulmonary Diagnosis/Symptoms: Route Results to (other physician) ame: Address: Fax: Authorization umber: ECHOCARDIOGRAPH D Echo w/ Color Flow Doppler (CFD) w/ saline bubble study w/ definity D LTD/Follow Up (o CFD) w/ saline bubble study w/ definity Stress Echo Treadmill Dobutamine STRESS TEST/UCLEAR CARDIOLOG Regular Treadmill Stress Test & uclear Stress Test with treadmill Chemical Schedule 2 day if > 275 lbs Stress Echo Treadmill Dobutamine Holter Monitor Day Event Monitor PULMOAR FUTIO STUDIES ABG (Arterial Blood Gas) Specify FIO2 required 94060, 94726, Complete PFT (PFT with bronchodilator, DLCO, Pleth) (Hold all inhalers 4 hours prior to test) Pre bronchodilator Spirometry Pleth (Lung Volume & Airway Resistance) Methacholine Challenge (Hold all inhalers/bronchodilators/ antihistamines 48 hours prior to testing) Exercise VO2 max metabolic study with Arterial Blood gases (at rest and peak exercises) min walk or Helios evaluation Treadmill with oximetry Exercise Provocation (Hold all inhalers/bronchodilators/ antihistamines 48 hours prior to testing) Pentamadine Aerosol Therapy EKG: o Appointment Required 7:30 a.m. - 5 p.m. Mon-Fri Ordering Physician Signature: Corresponding visit ID umber: *The above named ordering physician hereby authorizes this electronic signature for this exam as evidenced by their physical signature contained in the above referenced visit ID number. VASCULAR DEPARTMET Carotid Duplex Scan Ankle-Brachial Index (ABI) Unilateral Venous Arm Leg Right Left Bilateral Venous Arm Leg Arterial Doppler Arm Leg Lower Extremity Arterial Doppler Rest and Stress Unilateral Lower Extremity Arterial Duplex Right Left Biilateral Lower Extremity Arterial Duplex Unilateral Upper Extremity Arterial Duplex Right Left Biilateral Upper Extremity Arterial Duplex **Abdominal Aorta Renal Portal/Heptic SMA/Celiac **o food or drink after 10 p.m. Meds only with small amount of water. o gum or smoking morning of study. Date:

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3 CT Lung Screening Order Form Patient ame: Phone umber: DOB: / / Packs/day (20 cigarettes/pack): Currently smoking? Height: x years smoked: = pack years*: *Pack year calculator: If no, how many years since you quit? Weight: Ordering Physician (print name) : CT Lung Screening Exam Initial Repeat Follow-up Fax: Prior Authorization umber (low dose CT for lung cancer screening): Corresponding visit ID umber: Comments: By signing this order, I certify that: The patient is between the ages of 55 and 77. The patient has participated in a shared decision making session during which potential risks and benefits of CT lungscreening were discussed. The patient was informed of the importance of adherence to annual screening, impact of comorbidities, and ability/wilingness to undergo diagnosis and treatment. The patient was informed of the importance of smoking cessation and/or maintaining smoking abstinence, including the offer of Medicare-covered tobacco cessation conseling services, if applicable. The patient is asymptomatic (no symptoms such as fever, chest paint, new shortness of breath, new or chaaging cough, coughing up blood, or unexplained significant weight loss). Ordering Physician Signature: Date: Via (office Staff): *The above named ordering physician hereby authorizes this electronic signature for this lung screening order as evidenced by their physical signature contained in the above referenced visit ID number.

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5 PET/CT Order Form Please complete both pages First available appointment will be given unless otherwise specified. Patient Demographics Patient ame: Home Secondary Date of Birth: Male Female Weight (Limit 400 lbs): Height: Diabetic: Previous Radiation: Insulin Oral Diet If yes, date of last treatment: Body Area: Previous Chemo: If yes, date of last treatment: Has the patient had a previous PET scan for same cancer indication: Insurance Information Primary Insurance: Secondary Insurance: Pre-Authorization Required: Pre-Authorization umber: Diagnosis Code (required): To help determine medical necessity, please fax the following documents: Most recent H & P Most recent progress notes Outside pathology report(s) Outside radiology report(s) Patient demographics Reason for PET/CT Exam OCOLOG BRAI Standard Body (78815) (routine use) Alzheimer s vs Frontal Temporal Dementia (78608) Initial Treatment Strategy (PI) Epilepsy for Surgical Evaluation Subsequent Treatment Strategy (PS) Tumor Evaluation (78608) (Restaging or Treatment Monitoring) (reoccurance vs Radiation ecrosis) Whole Body (78816) (melanoma or cancer below knee) Initial Treatment Strategy (PI) Subsequent Treatment Strategy (PS) (Restaging or Treatment Monitoring) Standard Body with Brain (78815) (known or suspected brain mets) Initial Treatment Strategy (PI) Subsequent Treatment Strategy (PS) (Restaging or Treatment Monitoring) CARDIAC Myocardial Viability (78459) (to include oral dextrose and IV insulin) Baseline uclear Perfusion (78451) (to be ORDERED with myocardial Viability) af BOE SCA Whole Body Bone Scan CPT (78816) Ordering Physician Signature: Date: Via (office Staff): Corresponding visit ID umber: *The above named ordering physician hereby authorizes this electronic signature for this PET/CT order as evidenced by their physical signature contained in the above referenced visit ID number.

6 PET/CT Order Form Please complete both pages CT: Has the patient had barium in the last five days? Does the patient have an iodine allergy Does the patient have a previous exam related to this study? (If yes, please instruct the patient to bring them at the time of this study so as not to delay the results.) History of cancer? Is the patient diabetic? (If es : If requested exam requires iodinated contrast injection and patient takes diabetes medication containing Metformin, please contact Radiology or Central Scheduling for further instructions.) History of kidney impairment, disease, failure? Is the patient in renal failure? Is the patient pregnant or breast feeding? Patient weight Patient height Does the patient have special needs? (If yes, please explain) W W/O W & W/O Is the test being ordered with or without contrast? If exam requires IV contrast, GFR screening may be required. Consult Central Scheduling for conditions which may require lab work prior to exam. If exam requires oral contrast, please arrive 2 hours prior to exam..

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8 Radiology Scheduled Referral Form Central Scheduling (517) Fax: (517) Mon-Fri: 8 a.m. - 5 p.m. Last ame: Main Radiology (517) Fax: (517) First ame: MMP Imaging Center (517) Breast Care Center Grand Ledge Imaging (517) (517) Fax: (517) uclear Medicine Scheduling (517) MMP uclear Medicine Scheduling (517) Middle Initial: Date of Birth: Appointment Date: Appointment Time: Male Female Primary Insurance: Secondary: Authorization: Diagnosis/Symptoms: Route Results to (other physician) ame: Address: Fax: Other Instructions: Please call patient to schedule Patient to contact scheduling If exam needs to be cancelled, please notify department 24 hours in advance. Scheduled Exams/Appointment Required Arthrogram L-R (area) Barium Enema Barium Enema w/ Air Cholang Tube Cystogram-T Esophagus Hysterosalpingogram Myelogram ephrostogram/loopogram Sialogram (area) Sm Bowel Upper GI Upper GI/Sm Bowel Urethrogram V.C.U.G Venogram L-R (area) Other L L CT SCA (please also complete page 2) Abdomen Chest Chest for P.E. Chest Hi-Res Chest LDCT - diagnostic C-Spine Enterography Facial Head Kidney Stone Protocol Lower Ext. (area) Upper Ext. (area) R R L/S Spine Maxiofacial eck Pelvis Sinuses T-Spine Urography CTA Abdomen CTA Chest CTA Extremity - Upper CTA Extremity - Lower CTA Head CTA eck CTA Pelvis Other MAMMOGRAM Bone Density (DXA) Diagnostic Bilateral L R Diagnostic Unilateral Screening Add l MAM/US if Req. MRI (please also complete page 3) Abdomen Brain Breast Chest C-Spine L R Lower Extremity (area) L R Upper Extremity (area) L/S Spine MRA Abdomen MRAHead MRAeck MRAPelvis MRA Renal Pelvis T-Spine Other uclear Medicine Bone Scan (area) Gastric Emptying (liquid) Gastric Emptying (solid) Hida Scan Hida w/ CCK Scan Lung V/Q Scan Renal Scan Thyroid Uptake & Scan WBC Imgaing ULTRASOUD Aorta Abdomen L R Breast Bilateral L R Upper Extremity (area) Pelvis Pregnancy Prostate Renal Scrotum Thyroid Carotid Doppler Other Ordering Physician Signature: Ordering Physician (PRIT): Via (office Staff): Corresponding visit ID umber: *The above named ordering physician hereby authorizes this electronic signature for this exam as evidenced by their physical signature contained in the above referenced visit ID number. Date:

9 CT: Has the patient had barium in the last five days? Does the patient have an iodine allergy Does the patient have a previous exam related to this study? (If yes, please instruct the patient to bring them at the time of this study so as not to delay the results.) History of cancer? Is the patient diabetic? (If es : If requested exam requires iodinated contrast injection and patient takes diabetes medication containing Metformin, please contact Radiology or Central Scheduling for further instructions.) History of kidney impairment, disease, failure? Is the patient in renal failure? Is the patient pregnant or breast feeding? Patient weight Patient height Does the patient have special needs? (If yes, please explain) W W/O W & W/O Is the test being ordered with or without contrast? If exam requires IV contrast, GFR screening may be required. Consult Central Scheduling for conditions which may require lab work prior to exam. If exam requires oral contrast, please arrive 2 hours prior to exam..

10 MRI: Does the patient have stents or other metal implants? Does the patient have any body piercings? Does the patient have a pacemaker? Does the patient wear a pain patch? (if yes, it must be removed prior to MRI) History of brain aneurysm? History of cancer? History of heart surgery? History of metal in eyes? Is the patient diabetic? Is the patient claustrophobic? History of kidney impairment, disease, failure? Is the patient on dialysis Patient weight Patient height Does the patient have special needs? (If yes, please explain) Does the patient have a previous exam related to this study? (If yes, please instruct the patient to bring them at the time of this study so as not to delay the results.) Is the patient pregnant or breast feeding? Has the patient had surgery to the exam area? W W/O Is the test being ordered with or without contrast? W & W/O If exam requires IV contrast, GFR screening may be required. Consult Central Scheduling for conditions which may require lab work prior to exam.

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12 Radiology Walk In Referral Form Central Scheduling (517) Fax: (517) Mon-Fri: 8 a.m. - 5 p.m. Main Radiology (517) Fax: (517) MMP Imaging Center (517) Breast Care Center Grand Ledge Imaging (517) (517) Fax: (517) uclear Medicine Scheduling (517) MMP uclear Medicine Scheduling (517) Last ame: Date of Birth: First ame: Middle Initial: Male Female Primary Insurance: Secondary: Authorization: Diagnosis/Symptoms: Route Results to (other physician) ame: Address: Fax: Other Instructions: Walk In Exams HEAD SPIE UPPER EXTREMIT LOWER EXTREMIT Complete Sinuses Facial Bones L-R Mandible L-R TMJ Joints asal Bones eck Soft Tissue Orbits Partial Sinuses Skull-Complete Skull-Partial Bone Survey Cervical AP & Lat Cervical Complete Cervical Flex-Ext Entire AP & Lat Lumbar AP & Lat Lumbar Complete Lumbar w/ Bend Pelvis 1 View Scoliosis S.I. Joints Thoracic L R A.C Joint Bone Age Clavicle Elbow Finger 1 st, 2 nd, 3 rd, 4 th, thumb Forearm Hand Humerus Scapula Shoulder Wrist L R Ankle Bone Length Femur Foot Hip Knee Os Calcis Tib/Fib Toes Great, 2 nd, 3 rd, 4 th, little CHEST ABDOME Chest, PA & Lat Ribs Bilat w/ Chest Ribs L or R w/ PA Chest Abdomen AP (kub) Abdomen multi/view w/ PA Chest Ordering Physician Signature: Ordering Physician (PRIT): Date: Corresponding Visit ID umber: *The above named ordering physician hereby authorizes this electronic signature for this exam as evidenced by their physical signature contained in the above referenced visit ID number.

13 Radiology Locations DEWITT BATH 96 GRAD RIVER TO GRAD LEDGE SAGIAW ST. JOSEPH MT. HOPE AIRPORT WAVERL GRAD RIVER 3 4 CRETS LASIG MT. HOPE JOLL HOLMES WASHIG TO CEDAR EAST 27 PESLVAIA HACO 127 MICHIGA 1 2 LAKE 496 CAVAAUGH 69 LASIG COLLIS ABBOT 78 BURCHAM GRAD RIVER EAST LASIG 96 PARK LAKE MT. HOPE JOLL OKEMOS SAGIAW OKEMOS LOGA / MLK 99 ELIUS HOLT TO WILLIAMSTO 1 MCLARE GREATER LASIG 401 W. Greenlawn Ave. Lansing, MI (517) Fax: (517) MCLARE ORTHOPEDIC HOSPITAL 2727 S. Pennsylvania Ave. Lansing, MI (517) Fax: (517) GRAD LEDGE HEALTH CETER 1035 Charlevoix Dr. Grand Ledge, MI (517) Fax: (517) MMP IMAGIG CETER 1540 Lake Lansing Rd. Ste 107 Lansing, MI (517)