Laserfiche WebLink
• EXHIBIT "0" <br />Kittitas County <br />REFERRAL FORM <br />....... r Department <br />Referral for Chest X-ray to KVH -Imaging <br />Patient name: DOB: <br />----------------------------------------------------------------------- <br />Date of referral: _________________ Study requested by: Dr. Larson, Health Officer KCPHD <br />Date service needed by: 0 Stat or o __________________________ _____ <br />P a ti e n t s pea ks __________________________________________________________________ a n d may nee din te rp re ta ti 0 n . <br />Study needed: <br />o CPT 71010 Chest single view <br />OPA <br />or 0 Apical Lordotic <br />Reason for chest x-ray: <br />o CPT 71020 Chest two view o PAiLAT <br />o Rule out active TB disease due to 0 Positive PPD 0 Positive IGRA 0 Hx of treated TB disease <br />o High risk contact of active TB case <br />o Rule out active TB disease due to symptoms of 0 Cough 0 Fever 0 Weight loss <br />o the r p e rti n e n t i nf 0 rm a ti 0 n: __________________________________________________________________________________________________________________________________ _ <br />Result information: <br />o Please notify KCPHD at 962-7515 when digital image is complete and available to read <br />o 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 />o Me d i ca I co u po n ______________________________________________________________________ _ <br />o Insurance ________________________________________________________________________________ __ <br />o Patient has no insurance, bill Kittitas County Public Health Department <br />TB PRECAUTIONS NEEDED <br />o None <br />o 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 o Copy placed in KCPHD chart