Outpatient Procedure Request

This service is not intended for STAT or ASAP procedure requests.

CTA (CT angiography), MRI's, and Interventional Radiology cannot be requested using this form.

 

If you need to schedule an MRI or PET scan please call 517-364-2877.

 

If you need to schedule Tilt Tables or Tee's you need to contact the cardiologist group you want to perform the procedure.  If you are the cardiologist group then call Pre-Service.

All Nuclear Medicine require a prescription your office must fax an order to Ionia radiology at 517-364-3775. Failure to fax an order may result in the procedure getting canceled.

Important Notes: For ANY procedure requiring sedation, Sparrow Pre-Service must be called prior to scheduling.

There is a 24 to 48 hour turn-around time on each request submitted.

Please read each field carefully before submitting.

Thank you.

Sparrow Pre-Service
1-800-698-6329 or 517-364-3659, Monday - Friday 8pm - 5pm

 

****IF THIS IS FOR A BIOPSY OR ANY OTHER INTERVENTIONAL PROCEDURE YOU NEED TO GO BACK AND CHOOSE THE INTERVENTIONAL RADIOLOGY/IR CONSULT FORM. IF NOT THIS ORDER WILL BE FAXED BACK TO YOU AND YOU WILL HAVE TO EITHER CALL THE ORDER IN OR RE-DO ORDER WITH THE PROPER FORM.*****

  

Patient Information

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Patients Last Name:
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Patients First Name:
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Street Address:
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City/State/Zip:
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Date of Birth:
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Gender:

Male or Female

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Home Phone:
Work Phone:
Patients Email Address:
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Can Sparrow Central Scheduling speak with someone other than the patient to schedule the procedure?

Yes or No

Name:
Relationship to patient:

Guarantor Information

Guarantor Last Name:
Guarantor First Name:
Guarantor Birthdate:
Guarantor Phone:

Most insurance companies now require pre authorizations. You must have prior authorization for CT Exams, Nuclear Medicine Cardiolites & MUGA Scans before the test can be scheduled. Ordering providers must call AIM at 1-800-728-8008 for Blue Cross, McLaren at 1-888-327-0671, or PHP at 1-877-883-5689 to obtain an authorization number.

Authorization Number:

Insurance Information

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Primary Insurance:
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Policy Holder/Subscriber Name:
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Policy Holders Birthday
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Policy Number:
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Group Number:
Secondary Insurance:
Policy Holder/Subscriber Name:
Policy Number:
Group Number:
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Inhaler use:

Yes or No

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Medication allergies?
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This question MUST be answered for all exams ordered. Does patient have MRSA or VRE (Vanco Resistant Enterococcus)?

Yes or No

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Patient weight:
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History of allergy to Iodine or x-ray dye:

Yes or No

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If yes you must document a reaction or we will be unable to schedule
Medications patient is taking:

Avandament, Glucophage, Glucovance, Glyburide, Metformin, or Rosiglitazone

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Is patient on blood thinners?

Yes or No

Ordering Physician Information

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Physician name:
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Is this a Clinton Memorial Emergency Department Physician?

Yes or No

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Office phone:
Office fax:
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Office Contact:
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Referring / Primary Care Physician:
Office phone:
Office Fax:

Procedure Information

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Preferred Procedure Location:

Sparrow Hospital, SPB - Diagnostic Center, St. Lawrence Campus, Sparrow Clinton Hospital, Okemos Diagnostic, Ramblewood Imaging Center, Other (please specify)

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Procedure:
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Diagnosis:
ICD9 Code (Medicare Only)
Comments:
Common Radiology Exams:

Mammogram, B.E., UGI, IVP, Esophagram, Small Bowel Study

Please specify Ultrasound of the Neck/Thyroid or Ultrasound of the Neck Lymphadenopathy Exam. (Lymphadenopathy exams are for POST THYROIDECTOMY patients only - screening the lymph node chain for possible recurrence of cancer)

Neck/Thyroid, Neck Lymphadenopathy Exam

Ultrasound of:
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Are you scheduling a CT or Myelogram:

Yes or No

Myelogram of:

Cervical, Thoracic, Lumbar

CT of:
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Diabetic?

Yes or No

Is the patient 70 years or older?

Yes or No

Does the patient have any known kidney problems such as:

Kidney disease?

Yes or No

Renal Insufficiency/failure?

Yes or No

Kidney surgery or kidney transplants?

Yes or No

Any kidney injuries?

Yes or No

Does he patient have any certain disease e.g. multiple myeloma/systemic lupus erythematosia?

Yes or No

Is the patient on potentially nephrotoxic medications e.g.? Chronic high dose NSAID therapy? Aminoglycoside antibotics?

Yes or No

Does the patient have any cardiovascular disease?

Yes or No

History of CHF?

Yes or no

Pheripheral vascular disease (PVD)?

Yes or No

If yes to any of the above questions. GFR results are required within 30 days for all outpatinet (IVE iodinated constrast ct scans only)

PT GFR Level?
Date Labs were drawn
Where were labs drawn at?
Patients must be ambulatory to have a CT Scan. If not, they will need to have this exam done at the St Lawrence Campus. Is the Patient Ambulatory?

Yes or No

Sparrow's weight limit is 650 lbs/clinton and St. Lawrence is 450 lbs/Ramblewood is 400 lbs

Does the patient have prevoius history of allergy to x-ray dye?

Yes or No

Has the patient been placed on a steroid prep?

Yes or No

Has the patient had any previous CT's or other exams pertaining to the study?

Yes or No

Where were the studies performed?
Bone scan of:
Bone Scan Type:

Total or Limited

Scans:

Parathyroid Scan, 123 Thyroid Uptake Scan, HIDA Scan with Kinevac, HIDA Scan WITHOUT Kivevac, EEG, Other Radiology (Please Specify)

Cardiology Exams:

Cardiologist/Interpreter Name:

MSU Cardiology, Dr. Nagappan, Dr. A J Shah, Sparrow Hospitalist, Thoracic Cardiovascular Institute (TCI), Other (please specify)

Cardiology Exams:

Stress Test, ECHO, Stress Echo, Dobutamine Stress Echo, Pulmonary Function, Pediatric Echo, EKG, Holter Monitor, Other (please specify)

Cardiolite Type:

Adenosine, Dobutamine, Lexi Scan, Stress

Can patient walk a treadmill?

Yes, No, or Does Not Apply

For EKG and Holter Monitor, we must know if a patient has a pacemaker:

Yes or No

Event Recorder:

14 Day or 30 Day

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