PICC Team Order FAX orders to: 404.501.1795 Phone: 404.501.7588 Patient Information (Required for Scheduling) Patient Name: __________________________________ DOB: __________________ Sex:  MF SS#: XXX-XX-_____ First & Last Name Patient’s Address: ________________________________________________ __________________ _____ _________ Street City State Zip Code Home Phone #: _________________ Mobile Phone #: _________________ Email Address: ______________________________ Primary Insurance: __________________________ Policy #: _____________ Group #: _________ Insurance Phone #: _______________ Plan & Product Secondary Insurance: ________________________Policy #: _____________ Group #: _________ Insurance Phone #: _______________ Plan & Product Order Information - <PICC Team> Diagnosis: _________________________________________________________________________________ ICD CM Codes: _____________________________________________________________________________ Test/Service: _______________________________________________________________________________ CPT Codes: ________________________________________________________________________________ Purpose for PICC: ___________________________________________________________________________ Any Contraindications (*please circle*): mastectomy pacemaker dialysis patient (must have nephrologist ok) PICC Orders (*please circle*): PICC Insertion PICC Protocol PT/INR upon arrival (only if on Coumadin) Patient may be discharged after placement is confirmed Office Contact: ______________________________________________________________________________ Fax completed form to 404-501-1795 Send patient to DTC at 8 am. Take the M elevator (by the emergency department) to the ground floor. Referring Physician Information Physician Name (first & last): _____________________________________ NPI#: ________________ GA License #: _________________ Physician Address: _____________________________________________ Phone #: __________________ Fax #: __________________ I hereby certify that the services indicated in the above order form are medically necessary. Physician Signature: ___________________________________________ Date: ____________________ Time: __________________ DM Form #0000 (Rev. 8/2014)