Form Rad 2944 Lv PDF Details

Understanding the purpose and intricacies of the RAD-2944-LV form is essential for individuals requiring computed tomography (CT) services at the One Nolte Drive facility in Kittanning, PA. This comprehensive document serves as a crucial bridge between patients, their physicians, and the imaging service team, ensuring that all necessary information is communicated clearly and effectively before the CT scan appointment. The form encapsulates vital details such as patient identification, physician contact, diagnosis codes, specific preparation instructions tailored to the type of CT scan ordered, and insurance information to streamline the pre-registration and scheduling process. Highlighted within this form are diverse CT services, including scans for brain, chest, abdomen, spine, and more, each with specified preparation requirements to ensure the accuracy and efficacy of the diagnostics. Additionally, the form accommodates emergency situations with contingency order information. By providing a space for the physician’s signature alongside printed names and requiring the inclusion of the patient's name, date of birth, social security number, and insurance details, the RAD-2944-LV form plays a pivotal role in preparing patients for their CT scan, ensuring that the imaging team is fully informed and ready to deliver high-quality care tailored to each patient's needs.

QuestionAnswer
Form NameForm Rad 2944 Lv
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesImaging Services Computed Tomography CT Order General RAD 2944 LV 012213 hospital scan forms

Form Preview Example

 

Imaging Services

 

Computed Tomography (CT) Order

 

One Nolte Drive - Kittanning, PA 16201

Form # RAD-2944-LV

Imaging Service Scheduling 724-543-8131

Orig 2/93 Rev 1/13

Fax 724-543-8855

 

Place Label HERE

Contingency Order Info for MT Downtime

Room #

MR#

Acct #

Physician Signature

Physician PRINTED Name (required)→

Patient Name

 

 

 

 

 

 

 

 

 

 

Please follow the preparation listed below

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

and bring this form and any referrals needed

DOB

SSN

 

 

 

 

 

 

to the Outpatient Registration desk 1/2hour

 

 

 

 

 

 

 

 

 

 

 

 

 

before your appointment. If you have been

Address

 

 

 

 

 

 

 

 

pre-registered by phone, please arrive 15

Phone Number

 

 

 

 

Gender M / F

minutes before.

 

 

 

 

 

 

 

 

 

Primary Insurance:

 

 

 

 

DIAGNOSIS (Include ICD9)

 

 

Policy Number:

 

 

 

 

 

 

 

 

 

 

 

(Required)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Auth Number:

 

 

COMPUTED TOMOGRAPHY (CT)

Brain (prep CT#1)

Brain Unehanced

Sinus

Orbit/Facial Bones

Soft Tissue Neck (prep CT#1)

Chest (prep CT#l)

Chest Unenhanced

Chest Angio (PE)

High Resolution Chest

Abdomen (prep CT#2)

Required based on Insurance Policy

Appointment

Date:

Time:

 

 

 

 

 

AM / PM

Location:

 

 

 

ACMH Hospital

 

 

 

 

 

Imaging Center

Abdomen/Pelvis complete survey (prep CT#2)

Abdomen/Pelvis for Kidney Stones Pelvis (prep CT#2)

Cervical Spine with Reconstructions Thoracic/Dorsal Spine W/ Reconstructions Lumbar Spine with Reconstructions

CTA(prep CT#1)

Guidance for Abscess Drainage (prep CT#3) Guidance for Cyst Aspiration (prep CT#3) Guidance for Needle Biopsy (prep CT#3)

Patient Prep List

For Scheduling changes, please call: 724-543-8131

To Pre-Register for your appointment, please call 724-543-8832

A signed physician order is required at the time of your appointment.

Guidance for Radiation Field Placement Extremity with Reconstructions

Rt Lt (circle one)

Other

Baydoun Shoulder Protocol

CT Prep List

Prep CT#1 - Clear liquids only 6 hours prior to exam. Prep CT#2 - Clear liquids only 6 hours prior to exam, obtain bottle of Redi-cat from x-ray department and drink 2 hours prior to exam.

Prep CT#3 - Nothing to eat or drink after midnight.

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Form Rad 2944 Lv conclusion process described (stage 1)

2. After this segment is finished, you should add the required particulars in COMPUTED TOMOGRAPHY CT, Brain prep CT Brain Unehanced, prep CT Guidance for Abscess, Rt Lt, circle one, Other, Appointment, Date, Time, Location, AM PM, ACMH Hospital Imaging Center, Patient Prep List, For Scheduling changes please call, and To PreRegister for your allowing you to go to the 3rd part.

Time, Date, and prep CT Guidance for Abscess of Form Rad 2944 Lv

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