Pediatric Referral For Sedated Radiology Examination
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1Pediatric Referral for Sedated Radiology Examination
Please complete and FAX to One Call: 828-213-4877
Date of referral: __________________
Current (within 30 days) History & Physical is required to provide sedation service, and must be
FAXED to One Call by the appointment date or your patient will be rescheduled.
For questions, please call 0ne Call at 828-213-2222, option “2”, Mon-Fri 8AM to 5:30PM
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Prior APPROVAL Questions
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Please provide insurance information: Primary Insurance Co. ____________________________________
Secondary Insurance Co. _________________________________________________________________
1. Is one of these insurance companies providing coverage? BCBS __ Aetna __ UHC __
2. If one of the above is checked, please answer:
Yes_ No _
Is this referral for a CT, MRI or Nuclear Medicine exam?
If you checked #1 and answered YES to #2, Prior Auth #: ______________ is required BEFORE scheduling
your patient. If you checked #1 and you said NO to #2, no PA# is required. If nothing above applies, please
continue.
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Patient Information
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Patient’s Name: _______________________________________________________________
Patient’s DOB: ______________________________
Parent/Caregiver Name ________________________________________________________
Home phone: (
) ________________ Cell phone: (
) ___________________
Does parent give permission to leave message? Yes____ No____
****************************************** Physician/Clinical Information **********************************************
Exam Ordered: (eg: MRI Brain) _____________________________________________________________
With SEDATION: Yes __
With ANESTHESIA (Please indicate reason): ________________
Contrast (required): with_______ without _________ with and without_________
Contrast Allergy? Yes __ No __
Diagnosis: ___________________________________________________________________________
(Please do not use “Rule out” or “Evaluate for..” without also providing chief complaint)
Physician’s Signature (required): __________________________________________________________
Physician’s PRINTED Name:
___________________________________________________________
Physician’s FAX: _________________________________
Thank you for this referral,
Pediatric Sedation Team
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ONE CALL Appointment Completed
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After appointment is made, One Call will FAX this form back to you.
Appt Date/Time: _____________________________________________________
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ONE CALL Request Pediatric Nurse Follow-Up *******************************
One Call will call and schedule your patient. If the parent answers yes to any of the following issues, the exam
will NOT be scheduled until the pediatric nurse can call the parent back. After speaking to the parent, the nurse
will notify One Call to schedule, or will notify physician that a new referral will be needed.
Allergies to EGG, SOY, MILK
•
Prior adverse reaction or complications during anesthesia
•
Congenital Cardiac disease
•
Sleep apnea or obesity
•
Difficulty opening mouth or moving neck
•
Parent stated child has issue: _______________________, requesting pediatric nurse to call parent:
*********************************** NEW PHYSICIAN REFERRAL REQUESTED ***********************************
Pediatric Sedation Team did NOT APPROVE for SEDATION because: _________________________
In order to schedule this exam Mission Hospital REQUIRES a physician’s order W/O SEDATION or stating
WITH ANESTHESIA.
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