Get Physician Request Form For Oncologic Pet/ct ... - Cardinal Health

This guide provides a comprehensive overview of how to accurately complete the Physician Request Form for Oncologic PET/CT provided by Cardinal Health. By following these clear instructions, you can ensure that all necessary information is submitted correctly for efficient processing.

Follow the steps to successfully complete the form for submission.

1. Click the ‘Get Form’ button to access the form and open it for editing.
2. Begin with the 'Patient, physician and insurance information' section. Ensure that you input the patient's first name, last name, date of birth, and phone number. Include the patient's social security number, name of the insurance company, and the insurance company's phone number. Add the subscriber's insurance ID and any prior authorization number, if available.
3. Fill in the 'Worksheet completed by' section with relevant contact information and the 'Test date' and 'Test time' fields. Include details for the referring physician such as their first name, last name, phone number, fax number, and their signature (note that a stamp is not acceptable). Don't forget to enter the physician's NPI number and the date of form completion.
4. Provide additional patient information by indicating the patient's sex, diabetic status, and pregnancy status. If relevant, include the patient's weight and any pertinent medical history or physician progress notes. Ensure to send recent CT films to the provided contact.
5. In the 'Clinical history and type of scan requested' section, describe signs and symptoms and the diagnosis. You will also need to include the appropriate ICD-9 code. Specify why the PET/CT scan is being performed and detail any previous PET scans.
6. Choose the type of scan requested by checking the appropriate box based on the available options. Make sure to document any limitations related to Medicare coverage that could affect the patient's eligibility.
7. If a diagnostic CT is needed at the same time as the PET exam, check the relevant sections for the chest, abdomen, and pelvis.
8. Review all provided information for accuracy and completeness. Make any necessary modifications and finalize the form.
9. Once completed, you can save your changes, download the form, print it, or share it as needed.

Complete the Physician Request Form online today to facilitate timely and effective oncologic imaging.