Follow the steps to complete your Low Dose CT Lung Screening Request Form.

1. Click the ‘Get Form’ button to access the Low Dose CT Lung Screening Request Form. This allows you to open the document in an editable format, ready for completion.
2. Begin by entering the patient's name and date of birth in the designated fields. This information is crucial for identifying the individual being screened.
3. Indicate the patient's age within the range of 55-77 years by filling in the blank space provided.
4. Complete the pack year history section by calculating the patient's smoking history. Enter the value for packs per day (PPD) and the number of years they have smoked.
5. Specify the patient's current smoking status by selecting 'Yes' or 'No.' If the answer is 'No', provide the number of years since the patient quit smoking.
6. Fill in the referring physician's name, including the printed name and signature. Ensure to provide the physician's NPI number and the date of the request.
7. Enter the appropriate diagnosis code. Common codes include V76.0 for special screening or V15.82 for history of tobacco use, along with any other relevant codes.
8. Use the comments section to include any additional information or notes relevant to the patient's screening request.
9. After reviewing the information for accuracy, you can save your changes, download the completed form, print it, or share it as needed.

Complete your Low Dose CT Lung Screening Request Form online today to ensure timely and effective screening.