Work Flow for Radiology Research Orders
PREPARATORY RESEARCH (OPTIONAL)
Purpose:
To understand what radiology services will be performed for a particular protocol. It is not
uncommon that radiology services are not clearly detailed in the text of the protocol, potentially
resulting in additional unanticipated charges at the point of service.
The Department of Radiology supports and encourages clinical research at UCDMC. Investigators (PIs) are
encouraged to perform preparatory research in order to understand what Radiology services will be before
submitting a new research/grant budget. Department of Radiology will provide you with their assessment of
the required Radiology Services with CPT Codes.

The Department of Radiology highly recommends the PI work with a specific radiologist to discuss
the research study. This will help determine procedures required and assist with more accurate cost
estimates. Department of Radiology will also assist with CPT/GL codes.

Non-Routine Imaging Procedures: All research protocols/studies that involve non-routine imaging
studies, e.g. studies involving modified acquisition, processing, analysis, display, and/or storage, must
be reviewed and approved prior to study initiation.
To perform an evaluation of the Radiology Procedures please submit the following:
What to submit:
1. Research protocol
2. Research Procedure Request Form
a. Check box “Preparatory Research”
b. Fill only sections 1-10a
c. Signatures are not required
Send to:
Desirée Lazo
Administrative Research Coordinator, Department of Radiology,
4860 Y Street, ACC, Suite 3100; Sacramento, CA 95817
desiree.lazo@ucdmc.ucdavis.edu
Phone: (916)734-3651
Work Flow for Radiology Research Orders
PROCEDURE REQUEST (MANDATORY)
Purpose:
Procedure Requests are approved by the Department of Radiology and stored on file. The EMR-based
orders are compared with the request forms at the point of service. If the Procedure Request is not on
file with Radiology, the service will not be performed.
1.
Before beginning the Procedure Request form, you need to obtain DaFIS account, bulk account,
and Signature account (for professional fees). The Signature account is opened by checking “Type
of Charges: Professional” on the bulk account application form. These are necessary to complete
the request form process.
2.
What to Submit:
1. Completed Department of Radiology Research Procedure Request Form.
2. Copy of sponsor’s imaging protocol or a summary of imaging procedures
requested. If the PI is uncertain of the exams necessary, he/she must contact a radiologist
directly to obtain this information.
3. Copy of Human Subjects Review Committee (aka IRB) approval
4. Copy(s) of consent form(s)
5. Copy of the approved UCDMC bulk account application form with the DaFIS
account number. Signature Account is required for billing professional fees. The Signature
account is opened by checking “Type of Charges: Professional”. For information on Bulk
Accounts, contact Tom Rempfer at 734-9179, or
http://intranet.ucdmc.ucdavis.edu/researchbudgeting/.
ALL Radiology Research Procedure Request (Preparatory Research & Procedure Request) packets
should be submitted to:
Desirée Lazo
Administrative Research Coordinator, Department of Radiology,
4860 Y Street, ACC, Suite 3100; Sacramento, CA 95817
desiree.lazo@ucdmc.ucdavis.edu
Phone: (916)734-3651
Contact Information for Scheduling Radiology Research Orders
Davetta Vickers, MOSC V Supervisor
UCDMC Department of Radiology
Phone: (916) 703-2113, Pager (916) 762-0913
Davetta.Vickers@ucdmc.ucdavis.edu
The Department of Radiology is often confused with the Radiation Use Committee (RUC) when it comes
to the IRB request for an RUC approval letter. See http://ehs.ucdavis.edu/hp/rsm/forms.html for information
regarding the RUC.
The Imaging Center is no longer under the direction of the Dept of Radiology. If you desire their services,
you will need to contact them directly. This form may be used to request reads only on exams obtained at
the Imaging Center, but not for the services themselves.)
DEPARTMENT OF RADIOLOGY
Research Procedure Request Form
Preparatory Research (Please fill in 1-10a)
Procedure Request (Please fill in 1-10b)
NOTE: The Department of Radiology will no longer provide services for human research patients without a
valid UCDHS medical record number. It is the responsibility of the referring department to ensure that the
patient is properly registered.
Request Date:
Title of Study:
Project Start Date:
Project End Date:
1. Principal Investigator:
Dept.
Ph/fax:
2. Contact Person:
Dept.
Ph/fax:
3. Alternate Contact Person:
Dept.
Ph/fax:
4. Physician on Study (if not PI):
Dept.
Ph/fax:
5. Has the PI discussed this study with a Radiology faculty member? If yes, please name radiologist:
6. Description generally the goals of the study (please be brief):
Pager:
Pager:
Pager:
Pager:
7. What exam(s) are you requesting of Radiology (include CPT code(s), if known).



Location of study to be performed:
Main Hospital
ACC
Preferred time of study:
AM
PM
Weekend
Time requirements of procedure:
Modality requested:
CT
MRI
Diagnostic
Ultrasound
Interventional
Mammo
8.  Anticipated No. of Patients:

Other:
Nuclear
DEXA
Vascular Lab
# of exams per patient:
9. List any special requirements of Radiology services :
none
special reports
special views
new pulse sequences
Explanation for item(s) selected:
Image storage requested:
Image transfer:
Routine Procedure (Stentor)
yes To:
10a. Type of Research requested:
Film
no
Videotape
Disk
DAT
Special Formatting
(Film is $10/sheet and is ordered separately.)
Does the PI want to receive a copy of the report?
Yes
No
10b. List Funding Source(s) for Radiology services: (if funding is pending, please note that next to category)
NIH Grant
Private Sponsor
Professional Society
UCD/UCDMC
Other (specify):
DaFIS Account No.:
Bulk Account No.:
(If applicable)
Sub Acct.:
IRB number
For radiology department use only
Radiology Research Vice Chairman:
Radiology Imaging Manager:
Signature
Signature
Date
Date
Please return completed form to: Desirée Lazo, Administrative Research Coordinator,
Department of Radiology, 4860 Y Street, ACC, Suite 3100; Sacramento, CA 95817
desiree.lazo@ucdmc.ucdavis.edu; Phone: (916)734-3651