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Sample, Sammy G
ST0001
Lung Screening Intake Form
1234567890
Patient Name (Last)
Patient Name (First)
Date of Baseline CT
MM/DD/YYYY
Date of contact
MM/DD/YYYY
Medical Record Number
Study ID
Date of Birth
MM/DD/YYYY
Scanning Location
-
Mount Sinai Medical Center
Mount Sinai West
Mount Sinai Morningside
Brooklyn Heights
Kings Highway
Huntington/Greenlawn
Union Square / Beth Israel
Chelsea
34th St
Queens
Followed Elsewhere
Special Attention
VIP
Attending radiologist read
Comments
Primary Language (if not English)
Participant Program
Screening
Other
Specify
Research Protocol
Yes
No
How did you hear about our program?
-
brochure
doctor referral
friend in program
internet
lung screening program
medical journal articles
newspaper
radio
TV
word of mouth
other
Comments
Previous Comments
Contact Information
Address Line 1
Address Line 2
City
State
Zip
Country
Phone (work)
Phone (Home)
Phone (mobile)
Scheduling and Follow-up Calls and Letters
Phone Calls
0
1
2
3
X
Letters
0
1
2
3
X
Phone Call/Letter Information
Insurance Information
Medicare
Yes
No
Insurance 1
Insurance 1 Member ID
Insurance 1 Group Num
Insurance 2
Insurance 2 Member ID
Insurance 2 Group Num
Insurance Comments
Physician Contact Information
Physician 1
Name
Street Address
City
State
Zip Code
Country
Direct Phone
Office Phone
Fax
Email
Physician 2
Name
Street Address
City
State
Zip Code
Country
Direct Phone
Office Phone
Fax
Email
CT Orders and Authorization
Order Type
-
EPIC Order
Outside Rx
Scheduled by RA (Add-On)
Yes
No
LSO Required
Yes
No
CPT Code
-
G0297 / 71271
71250
Authorization Required
Yes
No
LSO Received
yes
Order Date
MM/DD/YYYY
Authorization Number
Order Expiration Date
MM/DD/YYYY
Authorization Expiration Date
MM/DD/YYYY
SDM Information
Required
Yes
No
Documentation Completed
Yes
No
Performed By
Date Completed
MM/DD/YYYY
Patient Status
Status
active
transferred to another institution (specify)
unable due to medical reason (specify)
unwilling due to personal reason (specify)
refused to continue
physician advised against
concern about radiation
moved and unable to return
no insurance, can't have Dx CT
burden of cost
other (specify)
excluded (specify)
study complete
no response to 3 calls + 3 letters
unable to contact
being followed elsewhere (get results)
expired (record date / cause)
Specify
Date of Death
MM/DD/YYYY
Cause of Death
Date of Exit
MM/DD/YYYY
Correspondence
Correspondence Date
MM/DD/YYYY
Date of Exam
MM/DD/YYYY
Coordinator
Recipient
patient
physician
Nature
-
faxed report
mailed report
called to give results
Abx discussed with physician
Bx discussed with physician
Pt. has MyChart
Mt. Sinai MD has EPIC access
Pt. has MyChart/MD has EPIC
other (specify)
Specify
Physician Name (if recipient)
Consent Information
Emailed consent form
Yes
Has the participant signed the consent form?
no [INELIGIBLE]
yes
Reason:
Attempted to contact (could not consent)
Coordinator
Date
MM/DD/YYYY
Reason
-
No answer
Phone disconnected
Wrong number
Need more time to consider
Other (specify)
Specify
Date informed consent signed
MM/DD/YYYY
Name of individual obtaining consent
Name of witness to consent
Witness date
MM/DD/YYYY
Witness comment
Have you given a copy of the consent form to the participant?
No
Yes
Did patient allow storage of information for use in future research studies?
No
Yes
Did patient allow use of information for DIRECTLY RELATED studies?
No
Yes
Did patient allow use of information for UNRELATED studies?
No
Yes
Would patient like to be contacted about further related studies?
No
Yes
Consented for the following projects
MR Blood
Date
MM/DD/YYYY
ID
U54 Control
Initial Date
MM/DD/YYYY
ID
3 Month Date
MM/DD/YYYY
ID
6 Month Date
MM/DD/YYYY
ID
12 Month Date
MM/DD/YYYY
ID
18 Month Date
MM/DD/YYYY
ID
24 Month Date
MM/DD/YYYY
ID
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