a referral form and schedule a mammogram appointment for the patient below. Scenario: Georgia Thompson needs to have her first mammogram appointment scheduled for her. She has transportation arrangements for Tuesdays and Thursday from 9:00am – 1:00pm. Her diagnosis is right breast - Cyst of breast and unspecified breast disorder - calcification. Georgia's last menstrual period was 05/27/XX. Copies of her mammogram need to be sent to Dr. Smith at 2121 College Drive, Suite 450, Middleton California, 55456. (916) 555-4321. Patient Demographics: DOB: 05/28/1955 Name: Georgia Thompson Insurance: Cigna ICD10: N60.01, R921 Phone # (209) 555-1234 ID #: U26183656 02 CPT: 77055 Authorization #: 135674
a referral form and schedule a mammogram appointment for the patient below. Scenario: Georgia Thompson needs to have her first mammogram appointment scheduled for her. She has transportation arrangements for Tuesdays and Thursday from 9:00am – 1:00pm. Her diagnosis is right breast - Cyst of breast and unspecified breast disorder - calcification. Georgia's last menstrual period was 05/27/XX. Copies of her mammogram need to be sent to Dr. Smith at 2121 College Drive, Suite 450, Middleton California, 55456. (916) 555-4321. Patient Demographics: DOB: 05/28/1955 Name: Georgia Thompson Insurance: Cigna ICD10: N60.01, R921 Phone # (209) 555-1234 ID #: U26183656 02 CPT: 77055 Authorization #: 135674
Phlebotomy Essentials
6th Edition
ISBN:9781451194524
Author:Ruth McCall, Cathee M. Tankersley MT(ASCP)
Publisher:Ruth McCall, Cathee M. Tankersley MT(ASCP)
Chapter1: Phlebotomy: Past And Present And The Healthcare Setting
Section: Chapter Questions
Problem 1SRQ
Related questions
Question
![Complete a referral form and schedule a mammogram appointment for the patient below.
Scenario: Georgia Thompson needs to have her first mammogram appointment scheduled for her. She has
transportation arrangements for Tuesdays and Thursday from 9:00am – 1:00pm. Her diagnosis is right
breast – Cyst of breast and unspecified breast disorder – calcification. Georgia's last menstrual period was
05/27/XX. Copies of her mammogram need to be sent to Dr. Smith at 2121 College Drive, Suite 450,
Middleton California, 55456. (916) 555-4321.
-
Patient Demographics:
DOB: 05/28/1955
Name: Georgia Thompson
Insurance: Cigna
Phone # (209) 555-1234
ID #: U26183656 02
CPT: 77055
ICD10: N60.01, R921
Authorization #: 135674](/v2/_next/image?url=https%3A%2F%2Fcontent.bartleby.com%2Fqna-images%2Fquestion%2F98d78473-cb2f-41ed-aed2-7586c2eeb117%2Fdf3dcf04-3798-482c-83d8-853dbf9d7ba7%2Fkyg6lvi_processed.jpeg&w=3840&q=75)
Transcribed Image Text:Complete a referral form and schedule a mammogram appointment for the patient below.
Scenario: Georgia Thompson needs to have her first mammogram appointment scheduled for her. She has
transportation arrangements for Tuesdays and Thursday from 9:00am – 1:00pm. Her diagnosis is right
breast – Cyst of breast and unspecified breast disorder – calcification. Georgia's last menstrual period was
05/27/XX. Copies of her mammogram need to be sent to Dr. Smith at 2121 College Drive, Suite 450,
Middleton California, 55456. (916) 555-4321.
-
Patient Demographics:
DOB: 05/28/1955
Name: Georgia Thompson
Insurance: Cigna
Phone # (209) 555-1234
ID #: U26183656 02
CPT: 77055
ICD10: N60.01, R921
Authorization #: 135674
![fraserhealth
BREAST HEALTH CLINIC REFERRAL
JIM PATTISON OUTPATIENT CARE AND SURGERY CENTRE
MSXX104484A
Rev: Feb. 11/11
Fax Completed Referral Forms to 604-582-3787
Page: 1 of 1
Phone: 604-582-4563
** INCOMPLETE DOCUMENTS WILL BE RETURNED**
Patient's FullI Legal Name:
Thompson
Georgia
Date of Birth: OS/28/1955
Last
Personal Health Number:
First
Midde
Gender: Female
Home Phone No. a16)555-4321
Okay to Call
Message Phone No.
Insurance Type
Interpreter Required:
Examination Requested
Mammography
No
Yes
Language:
FOR CLINIC USE ONLY
Breast Ultrasound
Rt
Lt
Bilateral
I understand and agree that referral to the Breast Health Clinic includes Medical
Imaging, a clinical examination (breast surgeon) and a core biopsy if indicated
Proceed to further imaging if indicated (Mammography/Ultrasound/MRI)
Arrange biopsy if indicated
Present Complaint: (see back for referral criteria)
Please Mark Area(s) of Concern:
Lump
Thickening
Nipple discharge/inversion/skin changes
Localized pain/tenderness
Dimpling, contour deformity
Previous breast cancer (new symptoms)
Abnormal Screening Mammogram
Re-referral to Breast Health Clinic
Right
Left
Bilateral
Follow up of previous findings
Specify:
Other:
History:
Menopause / LMP:
Previous Mammograms:
Yes
No
Location:
Date:
Hormone Therapy:
Yes
No
Location:
Date:
Previous Ultrasound:
Yes
No
Family History of Breast Cancer
Yes
No
Location:
Date:
Relationship
Age
Location:
Date:
Previous Biopsies/Surgeries:
Previous Images/reports requested
Date:
**Clinic appointment will not be booked until all previous breast imaging/reports received
Famly Physician (If different from referring source)
Referring Health Care Provider:
Name:
Name:
MSP #:
MSP #:
Phone:
Fax:
Phone:
Fax:
GP
Specialist
NP
Hospitalist
ER
Other
Patient has no GP/NP
Referring Physiclan Signature:
Printshop # 261984](/v2/_next/image?url=https%3A%2F%2Fcontent.bartleby.com%2Fqna-images%2Fquestion%2F98d78473-cb2f-41ed-aed2-7586c2eeb117%2Fdf3dcf04-3798-482c-83d8-853dbf9d7ba7%2Fanoz1np_processed.jpeg&w=3840&q=75)
Transcribed Image Text:fraserhealth
BREAST HEALTH CLINIC REFERRAL
JIM PATTISON OUTPATIENT CARE AND SURGERY CENTRE
MSXX104484A
Rev: Feb. 11/11
Fax Completed Referral Forms to 604-582-3787
Page: 1 of 1
Phone: 604-582-4563
** INCOMPLETE DOCUMENTS WILL BE RETURNED**
Patient's FullI Legal Name:
Thompson
Georgia
Date of Birth: OS/28/1955
Last
Personal Health Number:
First
Midde
Gender: Female
Home Phone No. a16)555-4321
Okay to Call
Message Phone No.
Insurance Type
Interpreter Required:
Examination Requested
Mammography
No
Yes
Language:
FOR CLINIC USE ONLY
Breast Ultrasound
Rt
Lt
Bilateral
I understand and agree that referral to the Breast Health Clinic includes Medical
Imaging, a clinical examination (breast surgeon) and a core biopsy if indicated
Proceed to further imaging if indicated (Mammography/Ultrasound/MRI)
Arrange biopsy if indicated
Present Complaint: (see back for referral criteria)
Please Mark Area(s) of Concern:
Lump
Thickening
Nipple discharge/inversion/skin changes
Localized pain/tenderness
Dimpling, contour deformity
Previous breast cancer (new symptoms)
Abnormal Screening Mammogram
Re-referral to Breast Health Clinic
Right
Left
Bilateral
Follow up of previous findings
Specify:
Other:
History:
Menopause / LMP:
Previous Mammograms:
Yes
No
Location:
Date:
Hormone Therapy:
Yes
No
Location:
Date:
Previous Ultrasound:
Yes
No
Family History of Breast Cancer
Yes
No
Location:
Date:
Relationship
Age
Location:
Date:
Previous Biopsies/Surgeries:
Previous Images/reports requested
Date:
**Clinic appointment will not be booked until all previous breast imaging/reports received
Famly Physician (If different from referring source)
Referring Health Care Provider:
Name:
Name:
MSP #:
MSP #:
Phone:
Fax:
Phone:
Fax:
GP
Specialist
NP
Hospitalist
ER
Other
Patient has no GP/NP
Referring Physiclan Signature:
Printshop # 261984
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