Follow the steps to successfully complete the CT Lung Cancer Screening form.

1. Press the ‘Get Form’ button to access the CT Lung Cancer Screening form and open it in your preferred editor.
2. Begin by entering the necessary personal information. Fill in your first name, last name, middle initial, date of birth, address, state, and zip code. Ensure all information is accurate to avoid processing delays.
3. Input your phone number in the designated field to facilitate any necessary communication.
4. Under the ICD-10 Codes and Clinical Symptoms section, provide any relevant codes that apply to your situation.
5. Select one option under the screening type: either 'Initial LDCT lung cancer screening' or 'Subsequent LDCT lung cancer screening'. Your choice should reflect your screening history.
6. Confirm the beneficiary eligibility criteria by checking the boxes that apply. Ensure that the beneficiary is between ages 55 and 77 and currently asymptomatic.
7. Indicate whether the beneficiary is a current smoker by selecting 'Yes' or 'No'. If 'Yes', enter the actual pack-year number, ensuring it is greater than 30 pack-years.
8. If the beneficiary is not a current smoker, answer whether they have quit smoking within the last 15 years. If 'Yes', provide the actual pack-year number and the number of years since they quit.
9. Attach proof of a provider-conducted lung cancer screening counseling and shared decision-making visit if required.
10. Ensure the provider signature field is completed and add the date of signing.
11. Review all entered information for accuracy. Once confirmed, save your changes, and proceed to download, print, or share the completed form as needed.

Complete your CT Lung Cancer Screening form online today to ensure your eligibility for this important health screening.