BirthName Date (Last) Maiden or Previous Name (First) Sex (M.I) M F Ordering Physician/Provider: PrimaryBirth Date Diagnosis(es) & ICD-9Maiden orCode(s)DIAGNOSTI Previous orName SymptomsCS AND ULTRASOUNDSex Ordering Physician/Provider: Nuclear Medicine and PET ScanM F DIAGNOSTIOUTOutpatientPATIENTC Order SORDER AND Form U FORMLTRASOUND Primary Diagnosis(es) & ICD-9 Code(s)OUTPA orTIENT Symptoms ORDER FORM Name (Last) (First)(First) (M.I) All orders require a signature from the provider to process Name (Last) (First) (M.I)
BiBirthrth Date Maiden or PrPreviousevious Name SexSex ProviderAll orders Signature: require______a signature from the provider______to process Birth Date Maiden or Previous Name Date Sex TimeM F Visit/Encounter # Unit Med. Record # Print Provider Name: ______M F PProviderPrimaryrimary Diagnosis(es)Signature:______& ICD-9ICD-10 Code(s) Code(s) or or Symptoms Symptoms______SPrimarychedul eDiagnosis(es) Appt Patie &nt ICD-9will ca llCode(s) 269-341-8700 or Symptoms Fax OrDatdere to 269-343-427Time 7 Visit/Encounter # Unit Med. Record # BPrintLH SProvidercheduling Name: 269-657-1441______BLH Fax 269-657-1339______Phys______ician will call DoesSAllch ordersedul patiente A pprequire meett criteriaP ata iesignaturen tfor will Hydration call 269-341-8700 from Protocol? the prprovider o videryesFax to O processrnoder Labto 269-343-427 result date 7______Allergies yes no GFR:______BAllLH orders Scheduling require 269-657-1441 a Creatinine:______signature BLH from Fax 269-657-1339the provider (within 30 to daysprocessPh ysof ischeduledcian will ca examll or new labs must be drawn) Allergy to X-ray Dye\Contrast yes no DoesPrProviderovider patient Signature: meetADDITIONAL criteria______for HydrationCLINICAL Protocol? DATA/SIGNS yes______& SYMPTOMSno Lab result date ______AllergiesADDITIONAL yes no INSTRUCTIONS Visit/EncounterVisit/Encounter # Unit MedMed.. RecordRecord ## GFR:______Provider Signature: ______Creatinine:______(within______30 daysDateDate of scheduled TimeTime exam or new labs must be drawn) Allergy to X-ray Dye\Contrast yes no THIS WEBSITE CAN BE USED IF YOU DO NOT HAVE YOUR OWN CLINICAL DECISION SUPPORT SYSTEM: PPrintrint ProviderProvider Name:ADDITIONAL______CLINICAL DA______TA/SIGNS & SYMPTOMSDate______Time Vhttps://qcdsm.nationaldecisionsupport.com/isit/Encounter # ADDITIONAL Unit INSTRUCTIONS Med. Record # Print Provider Name: ______CLINICAL DECISION NUMBER or SESSION ID:______ToSch Scheduleedule App callt 269-341-8700.Patient will call Fax269-341-8700 Order to 269-343-4277 Fax Order to 269-343-4277 DECISION SUPPORT APPROPRIATENESS SCORE:______DECISION SUPPORT VENDOR:______BLHSBBBCcLhHe SdulSchedulingchee Adulingppt 269-657-1441269-245-8666 269-657-1441Patient will ca B BBC llLBLH H269-341-8700 FFax axFax 269-657-1339269-245-4902 269-657-1339 F ax OrdReadPher ysto icand269-343-427ian fax:will call 7 DECISION SUPPORT ADHERENCE or CONSULTATION RESULTS:______BPleLHa Ssech reaedulingdNUCLEAR the 269-657-1441 following MEDICINE statem BLH Feaxnt 269-657-1339to the patient 's insurPhysaniciean co willm capallny and record the authorization number on the blank after the statement. "I am Does patient meet criteria for Hydration Protocol? yesSIGNS no AND Lab resultSYMPTOMS date ______Allergies yes no INTRAVENOUS______CONTRAST______GFR:______calling for authorizationEndocrine Creatinine:______ofSystem (the ordered pro (withincedur e30) for days both of scheduled the facility exam and or the new pr labsovid muster int beer pdrawn)retation." Allergy Auth otoriz X-rayation D Numbye\Contraster yes no . Does patient meet criteria for Hydration Protocol? yes no Lab result date ______Allergies yes no (Must check one box) TGFR:______Plehyroidase reaUptaGENERALd thekADDITIONALe and following Creatinine:______XRScaAYn statemCLINICALent D78014toA TtheA/SIGNS pati(withineGENERALnt &30's SYMPTOMS insurdays aof XRn scheduledceA Ycompa examny a ndor new*rPHYSICIAN’S/PROVIDER’SGEecoN labsErdRAL th must eXR aA uthYbe * Sodrawn)PrizECIALatio STnADDITIONAL AllergynumUDIESbe ORDERS tor X-rayon INSTRUCTIONSth eD yblae\Contrastnk aftUeLr TRASOUNDtheyes st a t e ment.no "I am * With IV contrast TchalyroidlCHEST/RESPIRing f oUptar authorizationke ATORY/RI of (the BordereS 78012d pUPPERrocedur eEXTREMITIES) for both the fa (Cont.)cility and the GASTROINTESTINALprovider interpretation." F ALuthUOROorization Number___ABDOMEN______. ADDITIONAL CLINICAL DATA/SIGNS & SYMPTOMS SPECIFIC EXAMS ORDEREDADDITIONAL INSTRUCTIONS Without IV contrast PaCHESTrathyroidGENERAL PA Gland & LAT (ROUTINEwith XR ASpecY )t 7102078071FOREARMGENERAL XRRTAY LT 73090 *GE*ESOPHAGUSNERAL XRAY *SPECIAL STUDIES 74220 ABD - COMPLETEULTRASOUND 76700 PET SCAN (Must check one box) * ThyroidCHESTCHEST/RESPIR Scan PA ON OnlyLY ATORY/RIB71010S 78018WRISTUPPER EXTREMITIES (Cont.) GASTROINTESTINAL*VIDEO FLUOROSCOPIC FLUORO74230 ABD - QUADRANTABDOMEN - SPECIFY 76705 PET-CT whole torso (eyes to thighs) 78815 CHESTNECK FOR PGastrointestinalA &SO LAFTT (ROUTINETISSUE System) 7036071020 FOREARM3 VIEW RT LT 7309073110 *ESOPHAGUSSWALLOW STUDY 74220 GALLABD - BLADDERCOMPLETE 7670576700 PET-CT limited (neck and thorax) 78814 LiPlveasCHESTRIerB BileSe (INCre adPTAranspoL ONUDEtheL Yfo PrAltl o ScanCHEST)wing statement71010 78226to theHANDWRIST patient's insurance company and reco*VIDEO*UPPERrd th eF GI LaUOROSCOPICuthorization numbe7424074230r on the LIVERABDblan k- QaUfteADRANTr the st a- tSPECIFement.Y "I a76705m Liver Bile Transport Scan w PET-CT whole body (skull vertex to toes) 78816 PcaleasNECKllingUNILe freo FORrAad TERALauthoriz theSOF foT laTIlotiSwingoSUnRT ofE st(theaLtementT ordere7036071101 78227tod theprocedur 3pati VIEWente')s forinsur boathn ctheeRT c ompf aciLlTityany7313073110 an adnd th ereco p*UPPERSroWrviderdAL thLeOW G.I. intauth e STUWITHrpretation."orizDY ESOPHAGUSation num Authbeo74240rizr oanti thone NumbPGALLblaANCREASnk BLADDER earft__er_ __the_ _st_a___tement.______"I_ a_76705m__ __. with Pharmacologic Intervention PET-CT brian 78608 caRIllingBBILS f(INCAoGENERALTERALr aLuthorizUDE PAa XRtiCHEST)onA Yof (the ordere71111 d procedurFINGERSHAND GENERALe) for bo thXR theARTY f aciLlityT 73140 and th*eGE p*UPPER*SMALLrNoEviderRAL XRBGI intOWELAYe *rpretation."SPECIAL STUDI AuthESo7424074250rization NumbRENALLIVER e TRANSPLANr__UL_TRASOUND______T ______7670576776____. G.I. Blood Loss Scan 78278 * CHEST/RESPIRUNILGENERALATERALABDOMEN XRATORY/RIARTY LTB71101S INUPPERF3AN VIEWTGENERALCOMPLETE EXTREMITIES XR UPPERARTY (Cont.)EXLT 73130 *GEGASTROINTESTINAL*UPPER*BARIUMNECRALT-INTERPRE XR G.I. ENEMAAY WITH *SPE C ESOPHAGUST I AA L TION S TUDI F74270/74280LUOROES 74240 PAORANCREASTA ULABDOMENTRASOUND 7670576775 Meckel’s Scan 78290 73092 * BILATERAL 71111 (0-18 MOS) G.EABDCHESTCHEST/RESPIR. Reflux FL APTA or PL& LAMilkATE/SUPINT (ROUTINE ScanATORY/RIE ) B740007104671020S 78262FOREARMFINGERSUPPER EXTREMITIESRT (Cont.)LT 7309073140 GASTROINTESTINAL*SMALL*POST*ESOPHAGUSCT OP( B OWELabdomenT-TUBE) F L CTUORO 759847425074220neck RENALKIDNEYSABD CT - pelvisCOMPLETE TRANSPLAN &ABDOMEN BLADDE CTTR thorax 767767677076700 ABDCHEST FL APTA &&ONABDOMEN UPRIGHLALYT (ROUTINET ) 74020710457101071020 FOREARMINWRISTFANTPECOMPLETELVIS AND UPPER RTHIPS EXLT 73090 *VIDEO*BARIUM*ESOPHAGUS*URINARY F LENEMAUOROSCOPIC SYSTEM 74270/742807422074230 SPLEENAORABD T- AQCOMPLETEUADRANT - SPECIFY 767757670576700 Gastric Emptying Scan 78264 73092 ABDNECKCHEST FLACUTE FOR APTAGenitourinary PL ONSO (INCALTE/SUPINFYTL TIUDESSSUE P ASystem CHEST)74022740007101070360 PEWRIST(3L0-18 VISVIEW APMOS) RT LT 7217073110 *VIDEO*POSTKSUBW AL(NO LOP( OWF LAPPOINTMENTUOROSCOPICT -STUTUBE)DY NEEDED)740207598474230 KIDNEYSABDGALL - BLADDERDOPPLERQU ADRANT& BLADDE - SPECIFR Y 939757677076705 RenoABDNECKRIBgrS FLam(INC FORA T(routine)L & UDESO UPRIGHHEADF TP ATI CHEST)STSUE 740207036078707HIPHAND3 VIEWPELVIS AND RTHIPS LT 7357311002 *I.*UPPERSVW. PALYE*URINARYLOW LGIOGRAM STUDY SYSTEM 7440074240 SPLEENLIVERGALL BLADDERPELVIS 76705 RenoSABDRIKBUNILULLgS r ACUTEam(INC COMPLETEA TERALGlomeLUDE (INC PrLAularUDES CHEST)RT P A CHEST)LT 702607402271101 PEHAND3L VISVIEW AP RT LT 7217073130 *CYSTOGRAPHYK*UPPERUB (NO G.I.GI APPOINTMENT WITH ESOPHAGUS NEEDED)744307402074240 ABDPLIVERPEANCREASLVIS - DOPPLER 768569397576705 78707 UNILBILATERALATERAL RT LT 7111171101 3 VIEW RT LT 73130 WITH ENDOVAG IF NECESSARY 76830 FiltFrACIALation RateBONES (GFR)HEAD 70150 HIPFINGERSLOWER EXTREMITIESRT LT 7357314002 *VOIDING*I.*SMALL*UPPERV. PYE LBG.I.OGRAM OWELCYSTOGRA WITH ESOPHAGUSM 74400744557425074240 SELECTRENALPANCREAS ONE D TRANSPLANIAGNOSTPEICLVIS TRANSPLANT T 7670576776 RenoMANDIBLESKBILULLgramA TERALCOMPLETE DiureticABDOMEN (Lasix) 70260701107111178708FEMURINFINGERSFANT COMPLETE UPPERRT EXLT 7355273140 *CYSTOGRAPHY*BARIUM*SMALL*MISCELLANEOUS B ENEMAOWEL 74270/742807443074250 AAAAORRENALPELVIS TSCREENINGA TRANSPLANWITHOUTT ENDOVAG76856767067677576776 73092 Renogram (Captopril) 7401878708(0-18 MOS) *ARTHROGRAM RT LT WITH ENDOVAG IF NECESSARY 76830 FORBITSABDACIAL FL A BFORTONES PLABDOMEN AMRITE/SUPIN SCREENINE G 701507003074000 INKNEEFANLOWERT COMPLETE EXTREMITIES UPPERRT EXLT *VOIDING*POST*BARIUM OP( ENEMA CYSTOGRAT-TUBE) M 74270/742807445575984 SELECTAFOLLICLEKIDNEYSAORORT AONE DI &A STUGNOSTIC BLADDEDY (ENDOR VAG ON768307677576770LY) Renogram Clearance Scan w 73092 WITHOUT ENDOVAG MANDIBLESINUSESABD FLAT &PL UPRIGHATE/SUPINT E 702207011074019740207400078707FEMUR(20-18 VIEWPE MOS LAP&LVIS) AANDT RTHIPS LT 7356073552 *POST(SPECIFY*URINARY*MISCELLANEOUS OP( WHICHT-TUBE) JOINT):SYSTEM 75984 SONOHYSTEROGRAMSPLEENKIDNEYS & BLADDER 76831/768567670576770 differential function ORBITSABD FLACUTEA FORT & UPRIGH(INC MRISPINEL SCREENINUDEST PA CHEST)G 700307402274020 PEKNEE3LVIS + PEVIEW APLVIS (SPECIFY) AND RTHIPS LT 7356472170 *HYSTEROSALPINGOGRAK*ARTHROGRAMUB (NO*URINARY APPOINTMENT SYSTEMRT NEEDED)MLT 747407402074018 FOLLICLEABDSPLEEN - DOPPLER STUOTHERDY (ENDOVAG ON768309397576705LY) Musculoskeletal System SINUSESCERVICALABD ACUTE AP (INC HEAD& LLAUDEST PA CHEST)702207204074022 LPEHIPEG2LVIS VIEW(TIBIA AP AP&L& FIBUATLA) RT LT 73560735907217073502 *SIA*I.K(SPECIFYUBV. LP(NOOGRAMYEL APPOINTMENTOGRAM WHICH JOINT): NEEDED)703907440074020 SONOHYSTEROGRAMAPPENDIXABD - DOPPLERPELVIS 76831/768567670593975 Bone Scan Total Body 78306 CESKULLRVICAL COMPLETE W/OBLIQUESSPINEHEAD (ROUTINE)7205070260 ANKLEHIP3 + VIEW (SPECIFY)RT LT 735647361073502 *HYSTEROSALPINGOGRASHUNT*CYSTOGRAPHY*I.V. PYE SURVEYLOGRAM 70250, 71020,M 74740744307440074020 BREASTPELVIS OTHERPE L VISRT LT 7685676645 Bone Scan Single Area Lumbar Spect 78803 CECERVICALFSACIALKULLRVICAL COMPLETE BONES FLEXAP & L&A EXTENDT ONL720407015070260Y LFOOTEG L(TIBIAOWER & FIBU EXTREMITIESLA) RT LT 7359073630 APPENDIXBIOPSYPELVIS ORWITH ASPIR ENDOVAGATION IF NECESSAR7685676705Y 76830 Bone Scan Single Area 78300 *SIA*VOIDING*CYSTOGRAPHYL*OGRAMULTRASOUND CYSTOGRAM OB 703907443074455 SELECT ONE CERVICAL LIMITED/circle option Specify______WITHWITHOUT ENDOVAG ENDO IF NECESSAVAGRY 76830 BoneCEMANDIBLEFACIAL RMarrVICAL BoONESw W/OBLIQUES Scan Total Bod(ROUTINE)y 72050701507011078104ANKLEHEELFEMURL OWER(OS CALCIS) EXTREMITIESRT LT 736107365073552 SHUNT*VOIDINGOB < 14*MISCELLANEOUS WEEKS SURVEY CYSTOGRA WITH 70250,M 71020,76801/76813 7445574020 SELECTBREAST ONE RT LT 76645 72040 WITHOUT ENDOVAG BonCEORBITSMANDIBLECOLLARe RMVICALarr FORo ONw FLEX Sc MRIa n&COLLAR SCREENIN MEXTENDultiple OFF ArONGeLa720407011070030Ys 78103FOOTTOESFEMURKNEE RT LT 736307366073552 *ARTHROGRAM*NUCHAL*MISCELLANEOUSULTRASOUND TRANSLUCENCYRT OBLT CAROTIDFOLLICLEBIOPSY OR STU ASPIRDY (ENDOATION VAG ON9388076830LY) BoneTSINUSESORBITSCHERO MarrVRIACCA FORIoLCw LIMITEDA PScan MRI & L ASCREENIN /cTLimited ir(RclOe UopT ItiNAreoGEn) a72070702207003078102HEELINKNEEF2ANT VIEW (OSCOMPLETE AP&LCALCIS)AT LOWERRT EXTLT 7356073650 OBO*ARTHROGRAM(SPECIFYB< < 1414 WEEKS WEEKS, WHICH WITH F OJOINT):LLRTOW 76801/7681376801/76816-UPLT CRANIALSONOHYSTEROGRAMFOLLICLESpecify______STUDY (ENDO 76831/76856VAG ON7650676830LY) 72040 73592 BonLSINUSESCOLLAReUMBAR Marrow ONAP and &SPINE WLABCOLLARTC (ROUTINE Count OFFSca)n 721007022078102TOES(320-18 +VIEW VIEW MOS AP&L (SPECIFY)) AT RT LT 735647356073660 *HYSTEROSALPINGOGRA(SPECIFYNUCHAL WHICHWITH TRANS ENLDOVAG UCENCYJOINT): IF NECESS M AR74740Y 76817 POPLITEALCAROTIDSONOHYSTEROGRAM AREAOTHER (e.g. bake 76831/76856r’s cyst)9388076990 SELECT ONE 76881, LimTLCERVICALitedUMBARHO RforAC II nfCWITH ecteAPAPSPINE &d OBLIQUE LArAtTTif icial(RO UJSToIinNtE) 72070721107204078803LINEGF3ANT +(TIBIA VIEWCOMPLETE & FIBU(SPECIFY)LA L)OWERRT EXTLT 7356473590 *SIA*HYSTEROSALPINGOGRAOB