Fillable Consultation Request To Oregon Health & Science University Form (Page 2 of 2) in pdf

Special Instructions and Information

Harold Schnitzer Diabetes Health Center • Adult Endocrinology and Clinical Nutrition

Indicate specialty: q General Endocrinology q Bone & Mineral q Lipid q Adult Diabetes q Pediatric Diabetes

q Attach recent lab values specific to Endocrinology/Diabetes/Lipid consult: (e.g. thyroid panels, lipid panels, glucose, HgA1C, Vitamin D)

q Attach imaging studies and other reports (e.g. DEXA, CT and Ultrasound)

q Pediatric: Growth Charts

Fibromyalgia – Division of Arthritis & Rheumatic Diseases

Please fax the following lab tests with medical records prior to scheduling to 503 494-1133:

q CBC with Differential q Sedimentation Rate q Insulin Like Growth Factor-1 (IGF-1) q Chemistry Panel q Vitamin D, 25 Hydroxy

q Hepatitis C Antibody q Thyroid Stimulating Hormone (TSH)

• Is pre-authorization required for PT and OT? (Please note: therapy services often require pre-auth, even if specialty visit does not) q yes q no

If yes, please provide authorization number: __________________________________________________________________________

Infectious Disease Clinic

NOTE: If the reason for referral involves one of the following conditions, please contact the appropriate clinic below:

• HIV – Internal Medicine HIV Clinic, contact 503 494-8562 for referral information/scheduling

• Hepatitis – Hepatology Clinic, contact 503 494-4373 for referral information/scheduling

THIS SECTION MUST BE COMPLETED IF REFERRAL IS FOR CHRONIC FATIGUE SYNDROME, POTS, EBV OR LYME DISEASE

• Is this patient currently on disability for this condition? q yes q no If yes, is their claim currently up for renewal? q yes q no

• Is this patient seeking to obtain disability? q yes q no If yes, is there a claim renewal in progress? q yes q no

We will provide the PCP with chart notes and diagnostic reports resulting from our examination and any treatment of your patient, however,

we do NOT complete disability paperwork.

Neurology

Indicate specialty: q Comprehensive (General) q Aging & Alzheimer’s q Multiple Sclerosis q Stroke q Epilepsy

q Neuromuscular/ALS q Movement Disorders/Parkinson’s

q Biopsy

q Deep Brain Stimulation

• MVAs, Worker’s Compensation, IMEs and Third Party Litigation referrals are typically not seen in the Comprehensive Neurology Clinic at OHSU

• Disability determinations are not seen or diagnosed in the Comprehensive Neurology Clinic

• Neurology does not provide Neuropsychological testing

• Neurology does not offer a chronic neurological pain management program

• If previously seen by a neurologist, must provide records

Pain Center

• Regardless of code pairing, Medicaid OHP/CareOregon/DMAP referrals require prior authorization for pain management.

• Pain clinic evaluation and treatment is specifically excluded from coverage according to Oregon Administrative Rule 410-120-1200.

Pulmonary Clinic

Please provide the following if they have been done:

q Chest X-ray report [actual imaging studies (hard copies or CD in DICOM format only) mailed to OHSU Pulmonary Clinic, Mail Code UHN-67,

3181 Sam Jackson Park Rd, Portland, OR 97239]

q Chest CT report [actual imaging studies (hard copies or CD in DICOM format only) mailed to OHSU Pulmonary Clinic, Mail Code UHN-67,

3181 Sam Jackson Park Rd, Portland, OR 97239]

q Most recent labs q Echocardiogram q PFTs q Cardiac Catheterization report q Biopsy report q Any other pertinent records

HCM 1058647 10/15

Consultation Request To Oregon Health & Science University Form Page 2