PSA between KVH and KCPHD (Xrays)

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• Kittitas County Public Health Department Patient name: Date of referral: EXHIBIT "D" REFERRAL FORM Referral for Chest X-ray to KVH - Imaging Date service needed by: ❑ Stat or ❑ Patient speaks Studv needed: FO: Study requested by: Dr. Larson, Health Officer KCPHD and may need interpretation. ❑ CPT 71010 Chest single view ❑ CPT 71020 Chest two view ❑ PA ❑ PA/LAT or ❑ Apical Lordotic Reason for chest x-ray: ❑ Rule out active TB disease due to ❑ Positive PPD ❑ Positive IGRA ❑ Hx of treated TB disease ❑ High risk contact of active TB case ❑ Rule out active TB disease due to symptoms of ❑ Cough ❑ Fever ❑ Weight loss Other pertinent information: Result information: ❑ Please notify KCPHD at 962-7515 when digital image is complete and available to read ❑ Health Officer will read the image, no need for a disc Billing information Patients with insurance will go through the normal billing procedure at KVH (please bill third party payers before billing KCPHD): ❑ Medical coupon ❑ Insurance ❑ Patient has no insurance, bill Kittitas County Public Health Department TB PRECAUTIONS NEEDED ❑ None ❑ TB Precautions as per your facility infection control policies: ■ Mask patient with regular mask ■ Isolate patient in room with door closed ■ Give patient instructions to cough and sneeze into tissue ■ Staff wear N95 TB mask ■ Notify your infection control coordinator ■ Close room for one hour after patient departs ■ If possible, ventilate room to outdoors and use HEPA filter and UV light ❑ Copy placed in KCPHD chart I'ny�'�•�I , r°,•.�I � !i!�}�'" lEsU #tl! {'+'i;Ti 1{a: . ;'! 7'S34>. Ii: E't":`#:� t'.. Ft+ v : i! 21?: { ...-'iijl i'i; {.!•:i'll ::ihtlj?� 7;:T-1`1 i�:'.:Il.j'u;:rl{7`,. [,,iS1L�Jll lGirly.:{�'71'l l�:l .I. •, ill! {:I�:. .i.".r I:L:I1 -4 L I ! •:II �:i