University of Calgary
Referral Form
*** As of December 1, 2008, AHCIP will only reimburse for screening colonoscopy in those at average risk for colorectal cancer from age 50 - 74 years. ***
Please note, all individuals seen at the Centre must be referred by a physician and meet the Centre's eligibility criteria.
Referrals must be made using the Centre's referral form, which must be fully completed.
Eligibility Criteria:
1. Age ≤ 74 years with valid AHCIP coverage and eligible reason for referral (see below).
2. Asymptomatic. No GI signs or symptoms requiring specialist consultation or diagnostic colonoscopy (i.e. rectal bleeding, anemia, change in bowel habits or other new GI symptoms).
3. No medical conditions that would increase the risk of sedation or colonoscopy.
4. Not on coumadin.
5. BMI < 40.
Eligible Reasons for Referral:
a) Average Risk Screening: 50 – 74 years, asymptomatic, no personal or family history of polyps or colon cancer (expected wait time > 18 months: all individuals should undergo annual FOBT ordered by referring physician until seen at CCSC).
b) Personal history of colon cancer or adenomatous polyps
c) Positive Fecal Occult Blood Test performed in an asymptomatic individual for colon cancer screening
d) Family history of colon cancer or adenomatous polyps (see screening guidelines)
AMA Colorectal Cancer Screening Guidelines (pdf)
AMA Colorectal Cancer Screening Algorithms (pdf)
______________________________________________________________________________________ 2008 Forzani & MacPhail Colon Cancer Screening Centre. All rights reserved.
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