98213 Appendices

1. Data Submission Checklist

2. Eligibility Checklist-Registration

3.CV Risk Calculator and Instructions    (Calculator Link)

4. Patient Medication Diary

5. WF Flyer  WF Brochure

6. Flow Sheet TAS

7. MRI Patient Information

8. Current Medication Form

9. Radiation Treatment Form

10. Chemotherapy Treatment Form

11. MRI Guidelines*  (See Helpful Guides Below)

12. MRI Encounter Form* (See Helpful Guides Below)

13. Lab Instructions

14. Telephone Contact Form

15. Physician Statin Update Letter

16-20: **To obtain these copyrighted forms:
1. Please click on the  "Patient Registration CCRBIS" on the left of the screen
2. Type your Username and Password.
3. Click on "I Accept"
4. Click on "Information" on the left side of the green bar at the top of the page.
5. Select "98213 Forms"
6. Print.

Contact Robin Rosdhal at rosdhal@wakehealth.edu  for password information. 

16. Baseline Neurocognitive Booklet**

17. Six Month Neurocognitive Booklet**

18. 12 Month Booklet**

19.  18 Month Booklet**

20. Twenty-four Month Neurocognitive Booklet**

21.  Early Withdrawal Form

22. Screening Form

 

*HELPFUL GUIDES: Please contact Sandra Soots at ssoots@wakehealth.edu with questions regarding these guides. 

MRI Guidelines

MRI Guidelines Non-Contrasted Exam

MRI Encounter Form

MRI Encounter Form - Non-Contrasted Exam

Medication Reference List

Site Flyer

Site Brochure

MRI Reimbursement Form

Back to 98213 Home Page

Quick Reference

Research Base

Fax 336-716-6275
Phone 336-716-0891

2000 West First Street
Protocol Information Office
Suite 101
Winston-Salem, NC 27104
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Last Updated: 08-13-2015
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Disclaimer: The information on this website is for general informational purposes only and SHOULD NOT be relied upon as a substitute for sound professional medical advice, evaluation or care from your physician or other qualified health care provider.