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Policy for Self
Requesting Mammogram
Comments:
Facilities in North Carolina that offer screening mammography may not
accept self-referred patients because a doctor is not involved. However
under 15A NCAC 11.0603 (a)(1)(G), they may accept self-requesting
patients. Facilities who accept self requesting patients, the
inspectors will be reviewing the policy. This policy shall document the
actions of the facility for self-requesting patients, following the
patient from point of contact to the end of the mammography procedure.
It is required that the listing of the doctor who will accept self
requesting patients be available. A mechanism shall be in place for
updating that list and this should be explained to the inspector.
As for facilities that do not accept self-requesting mammograms,
they MUST have a policy in place stating that fact.
Many facilities have chosen to offer
screening mammography on a self-requesting basis. These facilities are expected to
have a policy that outlines how such patients would be accepted. The policy shall address
the following situations:
a. The self-requesting patient must provide the facility with the
name of a referring physician who is willing to provide approprite
follow-up care. This information shall be confirmed by the
facility accepting it.
b. A facility accepting self-requesting patients shall maintain a
list of physician(s) who will accept the self-requestion patient for
follow-up care. Either the patient or the facility may select the
physician for follow-up care. The selected physician, by agreeing
to be on the list, is responsible for the appropriate follow-up and
treatment protocols.
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