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• <br />Kittitas County <br />Public Health <br />Department <br />Patient name: <br />Date of referral: <br />EXHIBIT "D" <br />REFERRAL FORM <br />Referral for Chest X-ray to KVH - Imaging <br />Date service needed by: ❑ Stat or ❑ <br />Patient speaks <br />Study needed: <br />c <br />Study requested by: Dr. Larson, Health Officer KCPHD <br />and may need interpretation. <br />❑ CPT 71010 Chest single view ❑ CPT 71020 Chest two view <br />❑ PA ❑ PA/LAT <br />or ❑ Apical Lordotic <br />Reason for chest x-ray: <br />❑ Rule out active TB disease due to ❑ Positive PPD ❑ Positive IGRA ❑ Hx of treated TB disease <br />❑ High risk contact of active TB case <br />❑ Rule out active TB disease due to symptoms of ❑ Cough ❑ Fever ❑ Weight loss <br />Other pertinent information: <br />Result information: <br />❑ Please notify KCPHD at 962-7515 when digital image is complete and available to read <br />❑ Health Officer will read the image, no need for a disc <br />Billing information <br />Patients with insurance will go through the normal billing procedure at KVH (please bill third party payers <br />before billing KCPHD): <br />❑ Medical coupon <br />❑ Insurance <br />❑ Patient has no insurance, bill Kittitas County Public Health Department <br />TB PRECAUTIONS NEEDED <br />❑ None <br />❑ TB Precautions as per your facility infection control policies: <br />Mask patient with regular mask <br />• Isolate patient in room with door closed <br />• Give patient instructions to cough and sneeze into tissue <br />Staff wear N95 TB mask <br />Notify your infection control coordinator <br />Close room for one hour after patient departs <br />• If possible, ventilate room to outdoors and use HEPA filter and UV light <br />❑ Copy placed in KCPHD chart ❑ Patient informed to call KCPHD after image is completed <br />❑ Health Officer notified that x-ray is ordered ❑ Health Officer notified that x-ray is completed <br />❑ Health Officer has received name, DOB, history of patient <br />::•i!{1a: Rev Ntiv 2JEW09: k Vj-rnt 2l7.FtirR:3, fir;.v.:.�,"Z[}'15 f•4cts• �f71fi <br />1C.()K4S�11JN111Y HEALTH :if: WC FSSC.onvrai:i,. irid f'nik'�AW s,ortw;+o5� KV9 f F' 3A fol CXN <br />