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-Kittitas County <br />Public Health REFERRAL FORM <br />...... Department <br />Referral for Chest X-ray to KVH -Imaging <br />Patient name: DOB : --------------------------- <br />Date of referral: _________________________ Study requested by: Dr. Larson. Health Officer KCPHD <br />Date service needed by: D Stat or D __________________________________________ _ <br />Patient speaks _____________ and may need interpretation . <br />Study needed: <br />o CPT 71010 Chest single view <br />DPA <br />or D Apical Lordotic <br />Reason for chest x-ray: <br />D CPT 71020 Chest two view o PAlLAT <br />D Rule out active TB disease due to D Positive PPD D Positive IGRA D Hx of treated TB disease <br />o High risk contact of active TB case <br />D Rule out active TB disease due to symptoms of D Cough D Fever D Weight loss <br />Other pertinent information: __________________________ _ <br />Result information: <br />D Please notify KCPHD at 962-7515 When digital image is complete and available to read <br />D 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 />D Medical coupon __________________________ _ <br />Dlnsurance ________________ _ <br />D Patient has no insurance, bill Kittitas County Public Health Department <br />TB PRECAUTIONS NEEDED <br />DNone <br />D 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 />o Copy placed in KCPHD chart D Patient informed to call KCPHD after image is completed <br />D Health Officer notified that x-ray is ordered D Health Officer notified that x-ray is completed <br />D Health Officer has received name, DOB, history of patient <br />inipicnlent,:·d "{ !1!OO', l"~e'l: '\ nrl J/08; t:~OV ?/l /'~/()rL !":·(!;v 1 ~~/G! j?: H ;'i!i:~I~d ~!!')/J!'l ~31 F~ev .~:\i2015 l'~Ov ~ ~?D 16 <br />C;:\C()f\!1~,:1Uf'HTY HE!\i :r: 1 SE:J~VICES\Conii;]ci~~ {:wid Po~i ... ::;;:~Xl b C()I)t!'<lc~s\'<VH P3l\ iOl CXH