Professional Documents
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Pllllenfs Primary lnsur:ance _ ..... -...,., Patienfs Secondary Insurance : Authorization Nuniber(s):
.; 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:
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)
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
\J
History/Special Instructions/Procedure Comments:
Page 1 of 1 S ura :
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IREllENltNG t>ROVXDER: MAYNA!\O,m:AN UW15
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
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 '
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.•
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
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 •