Reno Rad
Interventional Radiology Scheduling Form
Renown Regional Imaging Fax: 775-982-5602 Renown Regional IR Scheduling Office: 775-982-4933
Patient Name: __________________________________________________________________________
Procedure Date: ____________ Time: _____________
Patient Status: __ Inpatient __ Outpatient (physician order must specify status)
Procedure(s):
__ (49405) Drain Placement (location):__________
__ (49440-49441) G-Tube Option
__ (22521) Kyphoplasty, lumbar
__ (22523) Kyphoplasty, thoracic
__ (47000) Liver biopsy, needle, percutaneous
__ (32405) Lung biopsy
__ (38505) Lymph node biopsy
__ (72265) Myelogram
__ (10022) Neck biopsy
__ (50395) Nephrostomy Tube Placement
__ (36561) Port placement
__ (50200) Renal biopsy
__ (60100) Thyroid biopsy
__ Other: _________________________________
Diagnosis: ______________________________________________________________________________
Preferred Language: __English __ Spanish __ Other: ________________________________________
Special Needs (please check):
__Prisoner __Pregnant __Isolation
__Wheelchair __Gurney __Walker __Other: _________________________________________________
History of (please check): __MRSA __VRE __C.Diff.
Transfer from Care Center: Name of Care Center: _______________________Contact Phone: __________
Guardian/Power of Attorney Contact: _________________________________ Contact Phone: _________
CPT Codes: _________________________________ ICD 9 Codes: ________________________________
Patient name:__________________________________ __________________________________________
SSN:__________________________ DOB:_________________ Gender: ___Male ___ Female
Home Phone__________________ Work Phone____________________ Cell Phone___________________
Address:________________________________________________________________________________
Insurance __________________________________ Authorization #_________________ # Days_________
Name of legal guardian ____________________________ SSN: ____________________ DOB: _________
***** PLEASE ATTACH COPY OF INSURANCE CARD(S) *****
Scheduled By: ________________________________________________ Date/Time: _________________
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