Atch 5 Information for Proposed Physicians.docx

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?___________________

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

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