Conformed__Atch 5 Information for Proposed Physicians.pdf
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INFORMATION FOR PROPOSED PHYSICIAN SHEET
Complete the following worksheet for each key personnel and check each appropriate in columns 2 & 3
Name of Key Personnel: ________________________ IR or DR?___________________
Column 1 Column 2 Column 3
EXAM/PROCEDURE IS RADIOLOGIST WILLING
TO INTERPRET/PERFORM
THIS EXAM/PROCEDURE?
IS RADIOLOGIST
CURRENTLY
CREDENTIALED IN THIS
EXAM/PROCEDURE?
GROUP A (IR & DR)
Radiographs of any type Vascular and general ultrasound CT of all types (excluding CTA, CT colonography, and CT temporal bone) MRI of the brain and spine
GROUP B (IR & DR)
CTA of any type excluding CTA heart CT temporal bone CT colonography MRI of the entire musculoskeletal system excluding arthrography MR arthrography MRI of the liver MRI of the neck, pituitary, & IAC
GROUP C (IR & DR)
PET/CT with FDG PET/CT with axumin AND NaF
If the provider is currently credentialed in PET/CT, please include the total number of PET/CT’s interpreted in the last 36 months: _______________
GROUP D
Upper GIs and barium enemas Ultrasound guided paracentesis and thoracentesis Lumbar puncture and myelography Arthrography and intra-articular injections
Conformed to RFP Amendment 0003 - no changes this attachment
CT guided lung biopsy incl chest tube insertion
CT guided biopsy of deep abdominal structures
CT guided drainage including cholecystostomy
CT and ultrasound guided biopsy of superficial structures (incl thyroid)
GROUP E (ONLY IR FILL
THIS SECTION)
Percutaneous vascular access device placement
Percutaneous gastrostomy Percutaneous nephrostomy and ureteral manipulation
Dialysis fistula: diagnostic studies and intervention
Tube exchange Diagnostic and interventional (incl thrombolysis, stent placement, atherectomy & balloon dilatation) procedures of the lower extremity
Diagnostic angiography and intervention of the chest, abdomen and pelvis
Diagnostic and interventional venography
IVC filter placement Trans-arterial chemoembolization of the liver
Microwave and cryoablation of abdominal tumors
TIPS
Blood patch
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