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:__________________________ BDoesPleLHa S sepcatienth reaedulingd NUCLEARmeet the 269-657-1441 followingcriteria MEDICINEfor Hydrationstatem BLH Feaxnt Protocol? 269-657-1339to the pati eyesnt ' s insurnoPh Labysanic ieresultan co willm date capallny _______________ and record the a uth o Allergiesrization numyesbe r onon the blank after the statement. "I am SIGNS AND SYMPTOMS 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 nSTADDITIONAL 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 7670076705 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 NumbGALLPblaANCREASnk 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 NumbLIVERRENALe 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 AORSPLEENABD 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)759847402074230 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 740227026071101 PEHAND3L VISVIEW AP RT LT 7217073130 *CYSTOGRAPHYK*UPPERUB (NO G.I.GI APPOINTMENT WITH ESOPHAGUS NEEDED)740207443074240 ABDPLIVERPEANCREASLVIS - DOPPLER 768569397576705