Interventional Radiology/Consult Request

  

PATIENT INFORMATION

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Patient Name:
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Address:
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City:
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State:
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Zip Code:
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Date of Birth:
Gender:

Male or Female

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Home Phone:
Work Phone:

INSURANCE INFORMATION

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Primary Insurance:
Policy Holder/Subscriber Name:
Policy Number:
Group Number:
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Relationship to Patient:
Secondary Insurance:
Policy Holder/ Subscriber Name:
Policy Number:
Group Number:
Relationship to Patient:

PHYSICIAN/PROCEDURE INFORMATION

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Ordering Physician: (Must have Admitting privileges to order request)
Primary Physician:
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Procedure requested:
If this is for a liver biopsy, is it a core or targeted liver lesion biopsy:
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Ordering diagnosis with ICD9 code:
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Patient Weight:
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History of MRSA or VRE:
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Has patient had imaging studies pertinent to the procedure requested:

Yes or No

Where:
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Is patient allergic to Iodine Contrast / X-ray dye:
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Is patient Diabetic:

Yes or No

Is the patient taking Aspirin?

Yes or No

If taking Aspirin, 81 or 325 mg?

Please answer each one

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Is the patient on:

Blood Thinners, Coumadin, Warfarin, Plavix, Fragmin, Lovenox, Pradaxa

If yes, please specify:
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Contact person at office and phone number:

If you need an IR protocol form, please call 517.364.2686.

If you need an IR protocol form faxed, please provide fax number:
An Interventional Radiologist will review all requests once all paperwork has been received. A recent History and Physical is required (within 30 days) along with a current medication and allergy list. Outside imaging studies on a CD and all reports must be received prior to review.

Warning:
Depending on your patient's insurance type and coverage, some procedures may require a prior or pre-authorization before the test can be scheduled. For example: a CT Biopsy may require a pre-authorization. You must verify the patient's coverage prior to ordering.

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