CIRC Scheduling At Egleston

Request Form Fill out this form according to the following instructions and submit accordingly

Request Form: Patient Information For the patient information, please include all fields: Patient Name Date of Birth MRN Account/HAR #

Request Form: Parent/Guardian Information For the parent/guardian information, please include these fields: Parent/Guardian Name Phone Address City State Zip Guarantor Name Guarantor Date of Birth Guarantor Sex Guarantor Phone Relationship to Patient You DO NOT need to fill out the Insurance Information

Request Form: Exams to be Done In this section, check what exams need to be performed Be sure that checked procedure matches budget obtained from CIRC

Request Form: Study Information In this section, please include: On the first lines, write the patient diagnosis (ex: Chronic Kidney Disease) For diagnostic questions, include the short title of the study with the visit number (ex: XYZ123 Cycle 1 Day 1) For special requests, answer the sedation and portability questions. You can also include any specific instructions (ex: Complete exam 2 hours after first dose) For procedure completed, please include the date and time for the study (decided after talking to CIRC coordinators)

Request Form: Signature and Contact Information In this section, please include: Physician Signature Printed Name Date Office Contact – Coordinator/Nurse Information Practice Name (ex: Aflac) Phone Number Fax Number

Request Form: CIRC Exam CIRC Exam on date at time . On the top of the form, please write in “CIRC Exam on the date and time that was arranged with the CIRC coordinators

Sample Request Form

Request Form Submission Once your form is completed, send to schedulers at: Diana.Carr@choa.org (5-6476) Angelia.Richmond@choa.org (5-6476) As well as CC’ing: Kelsey.Zinck@choa.org (5-0628)

Egleston tips Please contact the CIRC coordinators before submitting the form to see if desired date(s)/time(s) are open Have multiple options ready that work for the patient Appointments are scheduled on the hour from 8:00-11:00 AM and 1:00 – 3:00 PM, Monday-Friday Submit form as early as possible (at least 48-72 hours) Check EPIC within 48 hours of submitting form to check for the appointment. If one is not in there, contact the CIRC coordinators or schedulers for assistance If your study utilizes both the PRC and CIRC, contact and coordinate with CIRC coordinators prior to submitting scheduling form *Prior to scheduling for a new study, send CIRC coordinators the Notice of Award* *If your study has Sibley Professional fees, send patient tracker to CIRC coordinators in addition to OGA*

Information for Coordinators for Study Visit Days (EG) Please stay with your patient in the waiting room until the sonographer comes out to get your patient. The sonographer may have questions pertaining to the study number, de-identification, etc. Provide the sonographer with a contact number in case they need to reach you If a CD or paperwork is required from the sonographer, those materials will be left in the research mailbox behind the sonographer’s office. For studies that require upload by a CIRC coordinator, please provide the coordinators with these materials from the mailbox if the sonographer hasn’t.

CIRC Scheduling AT Scottish Rite

Scottish Rite Contact and check with CIRC coordinators for available times prior to submitting form (we need to make sure sonographers will be available over at SR). Fill out CIRC Scheduling form according to instruction sheet (See slide 2 for request form completion instructions) if you do not have one, ask the CIRC coordinators for one and for an instruction sheet or visit http://www.pedsresearch.org/research/cores/cardiovascular-imaging-research-core-circ/overview/

Email completed form to CIRC coordinators (they will send on to SR schedulers) Check EPIC for the appointment within 48-72 hours. If no appointment exists, contact the CIRC coordinators for help Appointments/encounters CIRC creates with Scottish Rite will say Conf HOV, SR Rad Research

Orders in Epic Orders must be placed in Epic prior to study visit Ideally, having them placed on the day of or after the patient is checked in for their CIRC appointment works best Be sure to associate/link order to the SR RAD Research encounter that has been scheduled for your patient Be sure that the date on the order is correct

Scottish Rite tips Send scheduling form in at least 5-10 business days prior to your desired appointment time (earlier is always better for us at SR) You can call the CIRC coordinators for help (Kelsey 5-0628, CIRC line: 5-2472) If the appointment is not in EPIC, the CIRC staff do not know that the appointment exists and will not be able to complete the exam without issues!

Tips cont… The patient needs to be checked in to ALL appointments (including the Conf HOV, SR Rad Research) as present in order for the exam to be completed. Do this by asking the patient registration to check in the Conf HOV, SR Rad Research encounter On visit day, for EKG or echo appointment, take patient to the Radiology department (first floor), in exam room number 6. It says ‘noninvasive cardiology’ on the door Sonographers can be contacted on their Voalte phones as well as the desk phone: 5-6293

Contact Information Kelsey Zinck, MPH Desk: 5-0628 Email: Kelsey.Zinck@choa.org CIRC line 5-2472 Scottish Rite sonographers Voalte phone: 43293 or 470-565-3293 Desk: 5-6293 *Prior to scheduling for a new study, send CIRC coordinators the Notice of Award* *If your study has Sibley Professional fees, send patient tracker to CIRC coordinators in addition to OGA*

Thank you!

Once you have completed this training, please follow the link below to send a confirmation email. CIRC Training Confirmation