Cardiovascular Imaging Research Core Appointment Request Form Submission Instructions
This document provides detailed instructions for submitting the CIRC appointment request form accurately. It includes sections on patient information, study details, guardian information, exams to be performed, study information, and signature/contact details.
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Presentation Transcript
Cardiovascular Imaging Research Core CIRC Appointment Request Form Submission Instructions Updated 10/31/2024
CIRC Request Form Please follow the instructions provided in this presentation to accurately complete the information.
Request Form: Patient Information For the patient information, please include all fields: Patient Name Date of Birth Diagnosis MRN Account/HAR #
Request Form: Study Name/Location Always include the study name and location the study visit will be performed
Request Form: Parent/Guardian Information For the parent/guardian information, please include these fields: Parent/Guardian Name Phone Relationship to Patient You DO NOT need to fill out the Insurance Information Attaching the patient face sheet is encouraged.
Request Form: Exams to be Done Document which exams need to be performed Be sure that checked procedure matches the budget obtained from CIRC
Request Form: Study Information In this section, please include: On the first lines, write the patient diagnosis (ex: Chronic Kidney Disease) For diagnostic questions, include the short title of the study with the visit number (ex: XYZ123 Cycle 1 Day 1) For special requests, answer the sedation and portability questions. You can also include any specific instructions (ex: Complete exam 2 hours after first dose) For procedure completed, please include the date and time for the study (decided after talking to CIRC coordinators)
Request Form: Signature and Contact Information In this section, please include: Physician Wet Signature Printed Name Requested Procedure Date and Time Office Contact Coordinator/Nurse Information Practice Name (ex: Aflac) Phone Number
Sample Request Form
Request Form Submission Place Exam Orders in Epic Fill out CIRC Request Form Email Request Form to CIRC Coordinators CIRCResearchCoordinators@choa.org CIRCResearchCoordinators@choa.org 404-785-CIRC (2472)
Scheduling Request Tips Appointments are scheduled on the hour from 8:00-11:00 AM and 1:00 3:00 PM, Monday-Friday Investigator should put orders in prior to submitting appointment request. AB CARD IMAG RSCH CORE [549052] Orders should be submitted under Ancillary Performed Orders should include study name Submit form as early as possible (at least 48-72 hours) Appointments will be scheduled in Epic within 48 hours of submitting the form. Please contact the CIRC coordinators if you are unable to see the appointment.
Clinical Study Coordinator Expectations: Please remain with your patient in the waiting room until the sonographer escorts the patient to the exam room. Be prepared for questions pertaining to the study number, de-identification, etc. Waiting Room Provide the sonographer with a contact number in case they need to reach you. Contact Info Sonographer: Provide the team with study specific paperwork, checklist or CD for study transfer. CIRC Coordinator: Provide the team with necessary materials for study uploads. Documentation 12
Contact Information CIRC Coordinators Barbara.Nutall@choa.org Desk: 5-CIRC or 5-4799 Email: Barbara.Nutall@choa.org Barbara.Nutall@choa.org CIRC Sonographers AB Voalte phone: Ext: 41152 SR Voalte: SR Echocardiographer
Once you have completed this training, please follow the link below to send a confirmation email. CIRC Training Confirmation
