Get the free IMAGE-GUIDED OUTPATIENT PROCEDURE REFERRAL FORM - cedars-sinai

IMAGE-GUIDED OUTPATIENT PROCEDURE REFERRAL FORM To Schedule: (310) 423-8000 To Fax Orders: (310) 423-0137 Patient preps on reverse side. For exam information, please visit us at www.cedars-sinai.edu/ImagingPreps

How to fill out image-guided outpatient procedure referral

How to fill out an image-guided outpatient procedure referral:

1. Start by gathering all relevant information: Before filling out the referral form, ensure that you have all the necessary details related to the patient, such as their full name, date of birth, and contact information. Also, have the medical history and any relevant test results readily available.
2. Identify the procedure: Clearly state the specific image-guided outpatient procedure for which you are referring the patient. This could include interventions such as MRI-guided biopsies, ultrasound-guided injections, or CT-guided ablations.
3. Provide relevant medical information: Briefly describe the patient's medical condition that necessitates the image-guided procedure. Include any relevant signs, symptoms, or previous diagnoses. It is important to provide a concise but comprehensive summary of the patient's medical history to ensure proper evaluation and treatment.
4. Attach supporting documents: If the referral form allows for attachments, consider including any relevant medical imaging reports, pathology reports, or laboratory results. These documents can provide additional context and assist the specialist in making informed decisions regarding the procedure.
5. Include a primary care physician's information: Fill in the details of the referring primary care physician, including their name, contact information, and any additional relevant professional credentials. This information helps the receiving specialist communicate and coordinate with the referring physician if needed.
6. Patient consent and signature: Before submitting the referral form, ensure that the patient has given their consent for the procedure and understands the potential risks and benefits involved. Have the patient or their legal representative sign the form, acknowledging their agreement with the referral.

Who needs image-guided outpatient procedure referral?

Image-guided outpatient procedure referrals are typically required for patients who require specialized diagnostic or therapeutic interventions guided by medical imaging techniques. These referrals may be needed for individuals with conditions such as suspected tumors, complex joint or back pain, organ dysfunction, or other issues that require precise imaging guidance for accurate diagnosis or treatment.

It is primarily the responsibility of the patient's primary care physician, after evaluating the patient's condition, to determine whether an image-guided outpatient procedure referral is necessary. The primary care physician considers factors such as the patient's medical history, symptoms, and diagnostic test results when making this referral decision. Once determined, the referral is then made to a specialist or facility with expertise in performing image-guided outpatient procedures.

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What is image-guided outpatient procedure referral?

Image-guided outpatient procedure referral is a process in which a healthcare provider recommends a procedure that utilizes imaging technology to guide the treatment.

Who is required to file image-guided outpatient procedure referral?

The healthcare provider who recommends the procedure is required to file the image-guided outpatient procedure referral.

How to fill out image-guided outpatient procedure referral?

To fill out the image-guided outpatient procedure referral, the healthcare provider needs to document the recommended procedure, provide relevant patient information, and include any imaging studies.

What is the purpose of image-guided outpatient procedure referral?

The purpose of image-guided outpatient procedure referral is to ensure that patients receive appropriate treatment with the help of imaging technology.

What information must be reported on image-guided outpatient procedure referral?

The image-guided outpatient procedure referral must include details about the recommended procedure, patient's medical history, imaging studies, and any other relevant information.