Take Charge! Screening and Diagnostic Services Coupon Training

Before proceeding with training Use the speakers on your computer to hear the audio Be sure to have the Take Charge! Screening and Diagnostic Services Coupon (ODH Form No. 833) in front of you for easy reference Plan on completing and returning the self study Allow approximately 20 minutes for training

Training Agenda/Topics Goal and Objective Background Information Implementation Information Use of Take Charge! Screening and Diagnostic Services Coupon (ODH Form No. 833) Step by Step Instructions Self Study (Case Study)

Goal and Objective Goal – Provide an opportunity to gain knowledge and skill in completion of the Take Charge! Screening and Diagnostic Services Coupon (ODH Form No. 833) Objective -Upon completion of this self-study training participants will be able to: -Correctly complete the ODH Form No Understand the process of utilizing the coupon

Background Information ODH Form No. 833 is the result of combining the Mammography Coupon, Dysplasia Coupon, and Surgical Consult Coupon Shred all of the Take Charge! mammography coupons and dysplasia coupons upon receipt of the ODH Form No. 833 Issue a ODH Form No. 833 for each referral to diagnostic services

Background Information ODH Form No. 833 is completed by the Take Charge! healthcare provider that is referring for breast or cervical services It is critical that current findings and previous diagnostic services are completed so that the breast imaging, cervical services, and surgical consult providers have all pertinent information regarding your client

The coupon is three (3) page NCR (No Carbon Required format) – Write neatly using black ink – When using the coupons, do not write on a stack of coupons Instructions for completing the coupon are located on the back of the coupon for easy reference Background Information

Implementation Information ODH Form No. 833 is effective July 1, 2012 Services requested after August 31, 2012 on the old coupons will be denied until the ODH Form No. 833 has been issued To order additional ODH Form No. 833 complete the Take Charge! order form and fax it to or it to

Use of the ODH Form #833 Provide women with appointment information Communication tool from the referring healthcare provider to the breast imaging, cervical services, or surgical consult Data collection device Documentation for invoicing

Step by Step Instructions Part 1 ABC Community Health Center Lewis LisaA South LaneNorth CityOK73000 X X Key Items:  If the client doesn’t have a social security number, write “none”  If the client is homeless, notate on the address and phone number that it is a message phone or finding address  Ask the client with which race or races that they identify with, don’t guess None X X X Doe

Step by Step Instructions Part 2 and Part 3 Key Items: Part 2 is the section where you tell the healthcare provider what is currently occurring with the client that you are referring to them. Part 3 is the section that you use to tell the healthcare provider what happened in the past to the client that may affect the service you are referring to them. Normal No previous procedures 6/29/12

Step by Step Instructions Part 4 X Key Items: If you are referring a woman with an abnormal CBE (mass, bloody or serous nipple discharge, nipple or areolar scaliness, skin dimpling or retraction) please mark all of the possible services that the client might need and notate “if indicated”. First mammogram

Step by Step Instructions Part 5 and 6 Key Items: Complete the appointment date, time and facility information. This coupon is also used as a reminder for the client. Enter all of the referral information. Failure to provide information may delay receipt of results. X No Name Imaging Facility 1234 X-ray Avenue Imaging, Oklahoma :30 pm Don’t wear deodorant or jewelry Wear two piece outfit Give this coupon to the mammogram facility Dr. Pepper Take Charge Street Screening, Oklahoma

Final Instructions for Completing ODH Form No. 833 After completing the coupon, give the woman the first two copies of the coupon to hand carry to their appointment The last page of the coupon should be filed in the women’s chart for reference

Self Study Complete and return the following three case studies and fax them to Tia Yancey at Please allow 1 week for processing your case study A certificate of achievement will be sent to you upon successfully completion In order to complete the case studies, you will need three of the ODH Form No. 833 The case studies do not represent actual clients The audio portion of this training has ended

Case Study 1 Demographic Information: Name: Carol Smith Age: 43 DOB: 12/6/1969 Race: Asian Ethnicity: Non-Hispanic SSN: Address: 123 Street, Apple City, OK Daytime phone number: Not pregnant Meets income guidelines Doesn’t need an interpreter Clinical Information: Discrete palpable breast mass on left breast at 2 o’clock position. Mass has been there for 2 months. Thickening in the right breast. Client has no previous breast imaging Client needs to be referred for a diagnostic mammogram with a possible ultrasound and biopsy. Complete the ODH Form No. 833 for the following situation. Please use your clinic name and site number for the referring information. Pick a Take Charge! facility to schedule an mock appointment (don’t really schedule it). This case study does not represent a real person. This case study is for instructional purposes only.

Case Study 2 Demographic Information: Name: Anna Mena Age: 38 DOB: 2/20/1974 Race: White Ethnicity: Hispanic SSN: No SSN Address: 123 Street, Somewhere, OK Daytime phone number: Not pregnant Meets income guidelines Needs an interpreter Clinical Information: HSIL Pap test result on June 2, 2012 Client has a previous pap result of AS-CUS on January 2, Client received a Colposcopy at OU Dysplasia Clinic on January 17, 2008 for an LSIL. Client needs to be referred for a colposcopy Complete the ODH Form No. 833 for the following situation. Please use your clinic name and site number for the referring information. Pick a Take Charge! facility to schedule an mock appointment (don’t really schedule it). This case study does not represent a real person. This case study is for instructional purposes only.

Case Study 3 Complete the ODH Form No. 833 for the following situation. Please use your clinic name and site number for the referring information. Pick a Take Charge! facility to schedule an mock appointment (don’t really schedule it). Demographic Information: Name: Sara L. Short Age: 57 DOB: 4/15/1955 Race: Black Ethnicity: Hispanic SSN: No SSN Address: 456 Prairie Lane, Orange, OK Daytime phone number: Not pregnant Meets income guidelines Needs an interpreter Clinical Information: Abnormal CBE (discrete mass) on June 2, 2012 Diagnostic mammogram Bi-Rads ® 0 on June 3, 2012 Ultrasound Result 4 on June, 2012 at the Breast Imaging Facility Client needs a surgical consult This case study does not represent a real person. This case study is for instructional purposes only.

Next Steps Fax the three completed Screening and Diagnostic Services Coupon (ODH Form No. 833) to Tia Yancey at A certificate will be sent to you within 1 week of successfully completing the case studies

Contact Information For additional information or assistance with the Screening and Diagnostic Services Coupon (ODH Form No. 833) contact Tia Yancey at or