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01 / 02 / 2018 10:02 FAX 141000 1/0002

Revision: Dec, 2010


. Wayne Memorial H~spital RA0002
Positron Emwlon & Computed Tomography (ljETIC1J Order Requisition Form
Questions or to schedule patients please call: 919-587-4300 and press "2" I
- Please fax this fonn to WMH 91~7-4301 within 24 hours of schedulin ap
1-Patlenrs Last Name (leg•IJ: Patienrs First N•m• (legal) : I 2-Date Of Birth:

3..Physlclan's Name _._ .... a-..i.uP1-"1:


)0 ~"'""" C1 . ::, ,Y,\.

5-Viagnosls; IC0-9 Cod ea & Descriptions:


\?::o d Time:

l
State Zip

Appointment Scheduled Date: Appolnbnent Schedule<! Time:

l. s . I~ '\'.~
·vo.JIW........,..__,._,;
Pllllenfs Primary lnsur:ance _ ..... -...,., Patienfs Secondary Insurance : Authorization Nuniber(s):

History/Special Instructions/Procedure Comments: Priority (please circle): STAT or ROUTINE

.; Clinical History;
Primary question to be answered?
\QS-T c_I C\- \~\I Is Patient Diabetic? Cl Yes )fNo
If Medicare, choose one of the following uses of PET/CT:
Initial Treatment Subsequent Treatment
0 Patient not amenable to lnvasilre diagnostic O Stage unknown from MR, CT or Ultrasound and cpurse Patient STA!lJ:l PQ:lITR!;;ATMENT AND :
procedure of treatment wil <litter depending on results of PET(CT 0 Suspect recurrence
OR OR OR
D Determining opllmat anatomical location to D Conventional Imaging not sufficient for clinical D Patient has knoWo recurrence
perform invasive diagnostic procedure management and course of treatment wil l differ OR
depending on results of PET/CT o Checking for residual disease
OR
D PET/CT replaces other imaging when K is expected
that convenUonal study is insufficient far ciinical
management
OR
o Other
Cl 6rvast
If Medicare, choose one of the following uses of PET/CT;
Initial Trea1ment
D Patient has dislalt metastasis
I0 Patient has locoregional reai rrence or
Sub~quent Treatment
o Patient has advanced and metastatic breast
i cancer and change in therapy
Requl,..d to have reunt diagnostic imaging: OMR OCT o Other Date: Where:

CJ Restagln9 ThJt!:S!id ~ncer


If M&dicare:
0 Thyroid cancer of a fOlilcular cell origin meeting the criteria ot (J!Q~- AU.~ M!l§.I Bf PRE§E.Nr TO Mf;LM,EDICAR/i. ~Q~B~!ili. CR/TERJ~I
D 1-Prevtous lhyroidectomy 0 3-Serum thyroglobulin levels greater than 10 ~
D 2-Radioiodine ablation O 4-NegaUve 1-131 whale body scan

PET & PET/CT Indications currently covered by Medicare as of Oct 1, 2002:


Refer to Medicate a>verage ·ruiea foT full definitions of codM, restrictions. /imitations & conditions of COl!tl"'9"-
78811 PET; limited area (e.g., chest, head/neck) 78814 PET/CT; limited area (e.g., chest, head/neckj 78459 PET Imaging; metabolic evaluation far the
78812 PET; skun base to mid-thigh 78815 PET/CT; skull base to mid-th igh determination of myocardial viability
78813 PET; whole body 78816 PET/CT; whole body 78608 Brain Imaging, PET; l\Aelabolic Evaluation
(only 1 scan rover per year to 76606)
!l.!!!l!!!!!!l PETICT i• cowred ONLY in ainical oiluation• In which tile PET/CT retuits ITllY a..ist In avciding an invaalve diagnostic procedJre or in wllicti lhc PET/CT result& may assist In
determlring •n optimel anatomical IOCll!lon to perform an Invasive procedure. In general, for moBI llOlld tumors, a tissue diagnosis is made prior to .,e perlommce of PET/CT. Il!eRfora. l!!e !M

i==>-=,_ Man adjl61<:1 to standord imaging modaNties, staging distant 1T11tastael1 or reataging patients with loooregionlli rocummoo or meta•lll>io: and aa an adj..-.ct to standard imaging
modalitiae for monilaing responoe to treatment for locally lldvanc<od and metastatic diseue to delemine H1harapy shook! be changed.
TII · are co....red only for restaglng of recumml or residual tlwold cancers of lollrular call on gin that n..e """'1 prevfously treated by thyroklectomy and radioiodine ablation and a
senrn lhyroglOl>ulin greatl!rlhan 10 ng/ml and negative ~131 IMlole body scan. (Four distinct histol ogic types ore: Folllrular, Papilary, Hur11118 a>ll and An•pl"'*c)

CorJSulting Physician to obtain copies of r e s u t t s ' - - - - - - - - - - - - - - - - - - - - - - - - -


l'llaae reain a copy of II* ID rm ri 111e patient's rmd lea I rucord.

llllllNIWH
ORDER!
01 / 02 / 2018 10:03 FAX 1410002/0002
.@ "WAY.N ~E
Rev 02J08l20 17
Wayne Memorial Hospital
UN!: HllA"t.Tll CAR.E Radiology Order Requisition Form
RAOOOl
Question& or to schedule aUents lease call: 919-587-4300 and ress "2"
-p1e.ase fax this form to WMH @919-587-4301 within 24 hours of scheduling appointment.. Priority (plouo circle):
STAT or
Middle Initial : 2-0ata Of Birth:

C\. 3.L\1

Patlenrs Address: Street

Paliant's Primary Insurance (pl-'"'"' ottoch copy or Patient's Secondary Insurance:


p.-Clenr• ln•urenc. card M authoriZlltion with thill form)!

\J
History/Special Instructions/Procedure Comments:

,t Nuclear Medicine ,t Diagnostic Scheduled Proceduru "'CT Procedyru


78306 Q Bone Scan Routine Total Body 74220 IJ Esophagus Barium Swallow 70450 0 Head without contrast
74230 Q Modified Barium Swallow 70470 a Head with and withour
78315 Q Bone Scan 3 Phase(Osteomye/lt/s)
70491 Q Neel( With contras!
78300 Q Bone Scan Limited (specify) 74240 CJ Upper GI (with Air-Contrast If Ind)'
71260'!tfChesl with contnost (with CXR If Ind)'
74250 Q Small Bowel Serles
71275'CI Chest to Rule Out Pulmonary Embolism
74270 Q Barium Enema (with· Air Contrast If Ind)• a
74160 Abdomen with contrast
(with plain f'ilms if Indicated)"
78226 0 Hef>lllobUiary Routine (Gallbladder)
CJ Arthrogram (specify)--- - - - - a
74150 Abdomen without contrast

78227 0 Hepatobiliary CCK (EF)


62270 CJ Lumbar Puncture 74177~domen/Palvls with contras!"
74400 Q IVP (with Tomogram if indicated)' 72193 0 Pelvis with conlrut'
78582 0 Lung Scan Vent and Perf (with CXR)
74455 Q VCUG 72192 CJ Pelvis without contrast (RIO fracture)
78597 0 Lung Scan Quantitative (Pre-op)
74176 a Abdomen/Pelvis without contrast
78707 0 Ranogram Routine ( Kldnoy) CJ Myelogram
( RIO kidney stone)
78708 0 Renogram Lael• Q Cervical 62302
72125 0 Cervical Spine (with plain filme If ind)'
78013 0 Thyroid Scan Only (Te) 0 Thoracic 62303 72131 CJ Lumbar Spine (with plain films If Ind)'
78012 0 Thyroid Uptake (1123) Q Lumbar 62304 76382 0 Screening Sinus 0 Complete Sinus
78070 0 Parathyroid Sean Q Other _ _ _ _ _ _ _ _ _ __
79005 0 Therapy Hyperthyroid ~ pjaanostic Routine Procedures
a
70486 without contrast
78018 a 131 1we a Thyrogon
71020 0 Chest
a
70487 with eontraat
70488 O with and without
78264 0 Gastric Emptying Study 1101 aRibs (circle) Left Right
78472 0 Resting Muga Study [J Brain Lab
74022 OAbdomlnal Serles
78452 0 Sinisi! Perfusion 74178 a Urogram• (with KUB If Indicated)
74000 C KUB
78452 0 Pharmacological Perfusion Heart 77078 0 Bone Denalty Study
72170 0 Pelvis
a other (tpeclfyJ,_ _ _ __ a Biopsy (specify) _ _ _ _ _ _ _ __
70220 IJ Sinuses
,t Ultrasound Procedures 70260 lJ Skull 70250 Q Limited 0 CT Anglo (specify),_ _ _ _ _ _ __
0 Extremity ( s p e c i f y ) - - - - - - - - -
a
76775 Aorta
0 Left
0 ConlralndieaUon to Contrast
76705 0 Gallbladder 0 Liver 0 Pancreas (circle) Yes• No
Q Right
76775 0 Renal 'Non-Ionic Contnosl If Indicated"
0 Spine (specify) _ _ _ _ _ _ _ _ __
76817 0 Pelvis OB Tranovaginal "' Mammograms
76856 a Pelvis Non.QB Tr.insabdomlnaV with 1100Lumbar
77067 0 2D Screening Bilateral
76830 Pelvis Non.QB Transvaglnal (If Indicated) 2050 0 Cervical
G0202 0 3D Scaenlng Bilateral
93880 O Carotid Doppler 2072 CJ Thoracic
D Other (specify) _ _ _ _ _ _ _ _ __ 77067 ·52 Q 2D Screening Unilateral
93971 0 Venous Doppler
(circle) Leg Arm Len Right (specify) Left Right
v' Special Procedure/ Cardiac Call!
93923 a Artertal Doppler G0202·52 0 3D Screening Unilateral
5710 C AnlJlogl'illm Femo,..I wlPosslbJe R•vucut.rlotlon
( circl•) Leg Arm (specify) Left Right
Left Right
76S.1 CJ e,...at Complete (Lt) (RI) 77066 CJ 2D Diagnostic Bilateral
6V01 CJ Flstulagram
76642 0 Breast Limited (Lt) (RI) G0204 0 3D Diagnostic Biiaterai
Loft Right
76882 CJ US Extremity Non-Vascular· Limited
6904 0 Declo! wlpossible Revaseularizallon 77065 0 20 Diagnostic Unilateral
76536 0 Thyroid
Loll Right (specify) Left Right
60100 0 Thyroid FNA (Stand) or (Molecular)
36558 0 Permacath ln•ertlon G0206LT/RT IJ 30 Diagnostic Unilateral
(specify) Left Right
36581 0 Pormacath Exchange (specify) Len Right
76870 0 Testicular
32565 a Thoracentesls Left Right 371Q1 a IVC Filter Insertion 19061 IJ Stereotacllc Core Biopsy
(circle) Oiag (physician send orders for fluid) 37193 0 JVC Filter Removal (specify) Left Right
or Therapeutic 50435 a Nephrostomy Tube Change 19281 Q Locallzatlon
49083 0 Parecenlesio 50433 0 PCNL with OR (specify) Left Righi
{circle) Olag (phyalelan sand orders for ftuld) Loll Right
Cardiac CathetertzatJon 77053 Q Duetogram
or Therapeutic
0 Biopsy _ _ _ _ _ _ __ 93548 0 Left Heart (specify) Left Right
a Other _ _ _ _ __ __ 93460 a Right and Left Heart a other (specify) _ _ _ _ _ __
a Other (specify) _ _ _ _ _ __ __ __ _
Other Physician to obtain copies of results_ _ _ ________________________________
Please Mtaln •copy of this fonn in ttWt patient's medic.at nteord.

Page 1 of 1 S ura :
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INPI I 1962415000
IAU'l'KORIZATI~ t; 565152514-4
---- -------------------T------ ----------~---------------••w-•--•--------------------------------------- -- ~---------- - ---
AUTil0RIZJ\TI0N REMllRKS

-- suppiemental l);lta beq.iJl:i h<lJ:e ~teqory or Ca%e~-~;;~/~~; FCP and Obligation• 902 - Y72120 Number ot! ·
Visits: 52 (Afll'llORIZ~TI~ INCLUOBS Initi~l eva.l.uation I.U>:< as indicated Iraaqing as indicated ChemQtherapy as
indica.tec1 He<1ica.t.ion ~eJDQnt a:i indicated. J'Ollow up as indicated Con.,ult valid to sept 6, .2018) supplemental Data
en~ lle:i:e --

JIUltili.,,;tion tor Non VA 'c:are.1VJ\ tacil;ty ~ot · timely provide the required :service

Chiet Colllplaint 1 Mal19nant l.ymph<>n.a

Type oC Servicu EV11luation and Treatlnent .oncology reCerral Cor eye ~",

IUTrHORI~TlON lNCLIJOES Initial evaluation Lab.:i as im.Uc..ted Imaging.a:< indicated Chemotherapy a8 ine11cated Hadication
manilgQl!l8Pt u indicated Follow up 11'1 indicatect consult valid to sept 6, 2018
' .
tll?Off AOC:KPTANC8 or THIS · JWTl(ORIZATION TllB NON VA PROVIDER AGRKSS TO ACCEPr ~ PAYHBN'r AS J:>A.YMEN'r :m rot.I. n>R THE
S&RV!CZS DlliSCRIBED i!D'll::m. BY FJl:DERAL RBGULAT:ION, 38 Cl'R 17, 56, VA IS T.HB: PRIMARY AND !S>CCLUSIV?: PA:a:JI VOR THE KEDlCAL
~ IT AlffllORillES. Ni SUCH, YOU KJ\Y NOT BILL TIO: VB'l'SRAM OR ANY OTHER PART:t . li'OR ~ POR'I'l:ON OIT 7lfE CARI!: AIJ'l'HORIZEO BY
0

VA. tN ADDITION, THB NQf VA PROVl:DER J\G,RBKS TO SUBHtT ALL 1\mDI;CAL RECORDS ASSOCIA'l'&:D WITH THI$ AUTHORIZSD · VISIT/S TO
THt VA HgDIClll< C&HT&R rOR IHCLUSlOll llfTO TRt vg~gl\All'S ~SOICAL RB~ORO

OONI'INUJ;O OR ADDITIONAL SZRVICI>SI RKQUBSTS FOR ADOITIONhL DIAGNOS'l'IC TESTING, SERVICES, AND/OR tlURJIBL'£ MSDICJ>.I.
KQOillNEN'J' RllQUIRB PRIOR AOTl!ORIZAT:COO, Fl\IWRE TO Oll'l'AIN PRlOR Al.)'l'HORIZATl'.ON ll'OR SERVICES WILL RBSULT IN THB Dl!:NfAL OF
PAYHEm.
PLl:l\St SUllKIT ALL REQC!ltST.S FOR ADDITIONAL SBRVICES ON TllJE Kl>ICLOSED MEDICAL Cll:RTIFICATION/TREA'l'MENT 111.Ml AND F1\lC,
Alm/Go WITH KBOICAL, DOCUM!mTA'l'ION, TOI '

uroloqy, Clle110therapy, ftadiation, oncology, Heniatoloqy -910-343-5327

claims

-PLEJ>.Ss siima.T ClAIMS T01 8At.BM VAHC:; ATnn CB'tn'RAl'.>. nra IJNrr, i11ee ROANOKE m.vo, sl\t.KM, VA 2n53~ •**"Paper cia1m.:1
:suk:nisai<m• K~~ ~lATELY c!Ue tC> J>- VA claimos proce.sdnq sy;stem, the origiJ>al. claim (r<!d • white copy> is
required ~o en.,ure prooe.s.,,in11 and payment:, black Ii whit• copies will no longer be accepted and will be returned to tJ\e
aubmittinq Cacility. con!leqllently delaying payment.•

FOR VA USE ONLY


-----~---rw- --------------------------------~------------------ ---------------~------------------~~---------- --- --------
(5) l!TATE COE>B ) (6) COONT¥ COOB I (7) TYPE OF I (8) Y1U\R OF BIRrH ) \9) 'AAR I (lO) PURro5E I
I l PATIENT I I . l I
.• 3-7 I . 191 I 10 I U47 I 7 I 05 I
----------~------~~-- - -------~------------·------------------- --~ -------r-------------------- -- ------------------------
STATICtl OF .w1\ISDtcTION . I . (11) COOK 1 (12) SEX
I I MALE
Veterarus l\QninistrAtion
2300 RAMSEY STRJ;ET 1 SHORT TERM - 1
'
I \ l'!) PCll'I
1--------------------
met. . PROGaAH . I \ NO
1'1\YET?XVILLB ' ~ . 28301 I I
APPROVED SY <Name and Title) (!li;;)

TBLEPHONXI 910-482-SlSO CUMKINGS, R088~T V


OBPUT:t CJl:CEF OB' STAFF
.~ ---------------------------------- ~~ ------------ - --~-----~----------------------------------~--------- -- ----------------
. Inf'.oanation on Veterans Administration Program

11eC..p~oo of this req\lest t.o :;ender the pre,,cribed !5ervice.:i will. con.st.1.tute an aqreeraent which 1" .s\Jl:>ject .
to the rollowin9:
I. SBRVICBS. IC services.are not initiated, please retun> thi.s doclllll9nt to the station at JUrisc11ction with a briet
explanation. unles.s approved by th<i VA, services are limited 1.n type and extent to those shown,
II. ll!>llIOD OF \11\LXDITY. service raust be perto.nioed within tha period ot! val.idity iJ>dicatitd.
I t ·a lo~41r tirlie i.:i needed, pleai:ie reque"t an ext~n.sion.

III. R21'0RTS·. clinical n>porta Are reqUired wnen an eXM!lination only ha.s been reque,.ted. t>1e1uso

Opt;.O!Jt: Not. Defined


From: 89/ITT/17 10:39 Ill Page 3 Of 20

slll::mit reportl! p:rcimptly to the station or JUri.~ction.

rv.· STATEMENT OF ACCOUNTS. s\Ullait a statement 01! ACcoUl\t in yo~r usual manner, Your statement muist
·includo9: (1) Patient's Nanie1 12) Id.entific11:tion NO.; (3) TreatmQnt (CPT) and Date" Rendered1 and (4) ~e.ei.

v. FZ:ES. Fees claimed 111'1Y not exceed those mads to the general pUbl1c ror like ae:rv1qes.
v:i: • .llAYMENl'. l'ay1111mt by the VA :!'.or se>:Vice" rendeted and approved is payment in rull.
VII. llOSPITll;l.IZATrON. When a need 1!or hospital care 'is ind,icated, ple~e call the iitation 01! JUrisdJ.ction
tor a.s.siBtance in aclluittinq the vateran to a VA hospit~.

VIII, IN;IUXRIES. Additional infoJtDation when requirwd ~y be obtain~d by contacting the station or .;JUri:odiction.
UC. When :submittinq claims ror payment yau must includ.. the Nl?:t and. TaxonOll)y Code of! the rendering- practitioner, and
the NPI and 'l:axon01Dy Coda of! your orqanization. It!, under the HIPAA N.111: Final Rule ·
[httpr//wwW.cms.hhs.qov/NationalPrOVl:dentstandJ, your organization i:s an "atypic.l.l" provider rurnishinq "ervices "ueh as
taxi, home and vehicle modirications, insect control, l'labilitation, and respite services and is therefore ineligible
ror an NPI, it is irci>ortant t~t you indicate "IneJ.i91ble tor NPI" on your claim :Corm •

VA Form l0-7079 · Date l>rint..d: Sep O'J, 20l 7

Opt-out; Not Def I ned