Lab Tests, Forms, and Clinic Services

 

Clinic Interpreter Services

 x5-6262 (on-site Spanish)
x5-9607 (NYPH)

I. EXAMPLES OF REQUISITIONS, ORDER SHEETS, AND CONSULTATION FORMS:

·         Lab Order Sheet:  Fill these out with the ICD 9 code and your contact number.  Please make sure to include both your beeper number and the AIM clinic number x 6-6355 (in case your beeper is signed out).  It is especially important in case the lab needs to contact you or a covering physician regarding an outpatient lab value.

·         Radiology Order Sheet: Please make sure to include the ICD 9 code.  This form is used for Xrays, NIFS, Echo, DEXA, and mammogram tests. 

·         ICD-9 codes for mammograms are:

o        screening mammo is V76.12

o        patients with family hx V16.2

o        personal hx V10.3

o        high risk patients V76.11

o        follow-up of an abnormal mammogram 793.80

·         ICD-9 codes for bone DEXA are:

o        screening for osteoporosis V82.81

o        osteoporosis 733.0

o        osteopenia 733.9

·         For stat Xrays, write "WET READ" on the requisition, and send the patient down to VC1.

·         Outpatient Consultation Form: please use this form for all outpatient clinic referrals. Please make sure to write your name and location (AIM) legibly.  For patients with CPP insurance, document also the referring CPP attending name, and the number of visits allowed.

·         EKG Order Sheet:  You may also order same day or STAT EKG by marking it clearly on the order form.

·         Cardiovascular Stress Test Order Sheet

·         General Requisition:  used for carotid dopplers, urine, and stool tests.

·         PFT Requisition

·         Immunization Order Card (a.k.a. blue card): used only for medications or vaccines given in series

·         Culture and Sensitivity: Labs for throat, urine, stool, other cultures, please fill one of these out

·         EMG/EEG requisition

II. See NURSING RESOURCES and OTHER AIM CLINIC SERVICES for more services, including:

·         A list of medications and vaccines available in clinic

·         Instructions on ordering medications/immunizations/PPD placement in clinic

·         Other AIM Clinic Services (DM, PAP, Anticoagulation Clinics, etc.)

 

III. SOCIAL WORK AND RESOURCES FOR SPECIAL POPULATIONS

IV. OTHER FORMS

Several forms are kept in the Patient Representative area. These include:

·         Physical Therapy Referral Form

·         M11Q: Home Care Service Order Form: is a form from the City of New York that directs authorization for Home Attendant Services. A home attendant is someone who can assist with chore services and personal care (they have no health care training and can not administer medicines). Although most of us would like to have our shopping and laundry done by someone, we must remember that this service should only be ordered for patients who are truly in need of personal care services. See flyer for info on home care. The form is a little more involved (4 pages), and needs to be completed once a year for all patients receiving home services.

o        Step 1-Background info: The most important part is the past medical history (page 1) and a brief assessment from you of the patient’s limitations (page 2).  Be sure to list all diagnoses that will contribute to functional need.

o        Step 2-Patient’s needs: Fill out the bottom of page 3 only if you are sure that the patient needs the services that you can check off. If you are unsure what the patient's needs are, or are unsure whether he/she even qualifies for the home service, do not check anything off.  Write on the narrative page 4, “Would defer to your assessment.”

o        Step 3-Signature/contact info/date: Make sure this part (bottom of page 3) is completed or else the forms will not be accepted by CASA.
Once the form is completed, you can either give it to one of the clinic social workers or mail it in to CASA for intake/approval.  Usually patients will be contacted by CASA within one week to schedule a home assessment visit.  A decision on whether they will receive services is usually made within a month.

o       Click here for more info on the M11Q or a list of CASA mailing addresses

o       Main CASA Mailing Address: (see website for other CASA addresses)
HCSP
309 E. 94 Street
New York, NY 10128-5683

·         Grey Equipment Order Form: Only necessary for some supply company when ordering medical supply. Most often a regular prescription with your fax number is good enough to order stuff like wheelchair, canes, gloves.  Companies will fax you a completed form to sign.

·         Medicaid Ambulette/Livery Cab Transportation Form: can be filled out by Social Workers, who will ask for your signature

·         HIV test order form: rarely used by MDs, as they should be using the on-site counselors for pre and post test counseling

·         Proxy Form: also see index of website

·         Medicaid Override Form: This is needed when your patient exceeds the standard Medicaid benefits for doctor visits or prescriptions.

 

Printable Forms:

·         Form Letters for Patients (English and Spanish form letters for missed appts, lab recall, job absence)

·         AIM Anticoagulation Clinic Referral Form

·         AIM Diabetes teaching/management service Referral Form (no need for forms)

·         Naomi Berrie Diabetes Center Referral Form

·         Neuro 12 Psychiatry Referral Form

·         Pain Clinic Referral Form (pt should then call x5-7114 for appt)

·         Sleep Study/Clinic Referral

·         Factor V and VII Genetic Analysis Order Form

·         HIV Viral Load Order Form

·         NYPH Physical Therapy Interactive Referral Form

·         AIM Narcotic Safety Contract ( English | Spanish )

·         NY DOH Multi-language Proxy Forms 

·         NYPH Medical Record Release Form

·         VNS Plan of Care Form (PDF) (see VNS section also): This form enables you to order VNS home visits, Home Health Aide services, PT, Social Work services....

 

Help with Forms:

These forms sometimes may contribute to time management problems while you are seeing patients. Depending on the complexity of the information requested and how busy you are, one approach is to reassure the patient that you will be happy to fill their form after you finish seeing all your patients. Patients can leave you their mailing address or return to pick up the completed form from your secretaries later.

·         Medicaid Transportation Form MAP-2015: For patients who have mobility problems and are unable to take public transportation. This form is available in the modules or can be printed here. After completing the form, give it to the front desk staff to fax to 212-746-8260 (transportation office). Once they have the form, patients can then access the Columbia Dispatch Service at 212-746-4000.

·         The NY State Office of Temporary and Disability Assistance: Disability Determination Form