1. CIRC Scheduling At Egleston

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

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

4. 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

5. 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

6. 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)

7. 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

8. 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

9. Sample Request Form

10. Request Form Submission
Once your form is completed, send to schedulers at:
(5-6476)
(5-6476)
As well as CC’ing:
(5-0628)

11. 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 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*

12. 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.

13. CIRC Scheduling AT Scottish Rite

14. 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

15. Email completed form to CIRC coordinators (they will send on to SR schedulers)
Check EPIC for the appointment within 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

16. 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

17. 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 , CIRC line: )
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!

18. 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:

19. Contact Information
Kelsey Zinck, MPH
Desk:
CIRC line
5-2472
Scottish Rite sonographers
Voalte phone: or
Desk:
*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*

20. Thank you!

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