Radioiodine Therapy | Forms & Documents

Schedules & Patient Instructions for Diagnostic Testing

Diagnostic rTSH-Stimulated 123-I Whole Body Scan and Serum Thyroglobulin

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Patient Instructions & Schedule

Diagnostic rTSH-Stimulated Serum Thyroglobulin Testing Only

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Patient Instructions & Schedule

Diagnostic rTSH-Stimulated PET/CT Scan and Serum Thyroglobulin

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Patient Instructions & Schedule

Schedules & Patient Instructions for Radioiodine Therapy

Postoperative Thyroid Remnant Ablation after rTSH (without Preceding Radioiodine Diagnostic Scan)

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Patient Instructions & Schedule

Postoperative Thyroid Remnant Ablation after rTSH (with preceding 123-I Diagnostic Scan)

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Patient Instructions & Schedule

Postoperative Thyroid Remnant Ablation after rTSH (with preceding 131-I Diagnostic Scan)

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Patient Instructions & Schedule

Postoperative Thyroid Remnant Ablation after Thyroid Hormone Withdrawal (with preceding 123-I Diagnostic Scan)

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Patient Instructions & Schedule

Postoperative Thyroid Remnant Ablation after Thyroid Hormone Withdrawal (with preceding 131-I Diagnostic Scan)

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Patient Instructions & Schedule

Dosimetric Radioiodine Treatment of Iodine-Avid Thyroid Cancer after rTSH

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Patient Instructions & Schedule

Dosimetric Radioiodine Treatment of Iodine-Avid Thyroid Cancer after Thyroid Hormone Withdrawal

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Patient Instructions & Schedule

Coordination of Care & Coverage Documents

Physician Coordination of Care Form

Physician Coordination of Care Form

Patient Insurance Coordination of Care Form

Patient Insurance Coordination of Care Form

CPT Codes for Payer

CPT Codes for Payer

Precertification Request

Precertification Request

Letter of Medical Necessity

Letter of Medical Necessity

Nuclear Medicine Request to Obtain Insurance Verification

Nuclear Medicine Request

Recombinant TSH Order Sheet

Recombinant TSH Order Sheet

Thyrogen One™ Order Sheet

Thyrogen One™ Order Sheet

Recombinant TSH Injection Request Form

Recombinant TSH Injection Request Form

Recombinant TSH Personal Physician Injection Request Letter

Recombinant TSH Personal Physician Injection Request Letter

Recombinant TSH Tracking Form

Recombinant TSH Tracking Form

Radioiodine Therapy Documents

Patient Instructions

Low Iodine Diet Instructions
Pretreatment Instructions
Instructions on Treatment Day
Follow-up Recommendations
Steroid Treatment Instructions

131-Iodine Treatment Dose Selection Data Form

131-Iodine Treatment Dose Selection Data Forms

Nuclear Medicine Pre-Treatment Scan Requisition

Nuclear Medicine Pre-Treatment Scan Requisition

Nuclear Medicine 131-I Treatment Requisition

Nuclear Medicine 131-I Treatment Requisition

Nuclear Medicine Post-Treatment Scan Requisition

Nuclear Medicine Post-Treatment Scan Requisition

Radioiodine Consent Form

Radioiodine Consent Form

Documentation of Radioactive Dose Administration

Documentation of Radioactive Dose Administration

Patient Self-Reported History Form

Patient Self-Reported History Form

Physician Note Templates

Postoperative Radioiodine Thyroid Remnant Ablation after rTSH Preparation

Postoperative Radioiodine Thyroid Remnant Ablation after rTSH Preparation

Postoperative Radioiodine Thyroid Remnant Ablation after Thyroid Hormone Withdrawal

Postoperative Radioiodine Thyroid Remnant Ablation after Thyroid Hormone Withdrawal

Follow-Up of Thyroid Cancer at Post-Treatment Scan (after Preparation with rTSH)

Follow-Up of Thyroid Cancer at Post-Treatment Scan (after Preparation with rTSH)

Follow-Up of Thyroid Cancer at Post-Treatment Scan (after Preparation with Thyroid Hormone Withdrawal)

Follow-Up of Thyroid Cancer at Post-Treatment Scan (after Preparation with Thyroid Hormone Withdrawal)

Follow-up of Treated Thyroid Cancer

Follow-up of Treated Thyroid Cancer

Follow-Up of Treated Thyroid Cancer after Recombinant TSH-Stimulated Testing

Follow-Up of Treated Thyroid Cancer after Recombinant TSH-Stimulated Testing