Follow the steps to complete your form accurately.

1. Press the ‘Get Form’ button to access the form and open it in your document editor.
2. In Section 1, fill out the member demographics. Provide the patient's first and last name, date of birth, health plan name, member ID number, and group number.
3. Section 2 requires the ordering provider's information. Enter the physician's first and last name, primary specialty, NPI number, tax ID, phone number, fax number, and contact name.
4. In Section 3, complete the facility information. Include the facility name, tax ID, address, city, phone number, fax number, NPI number, state, zip code, and the date of service.
5. Proceed to Section 4 to detail the exam request. Input the CPT codes, a description of the procedure, ICD diagnosis codes, and descriptions. Additionally, document the date of the first office visit and the most recent office visit for the condition with any provider.
6. In Section 5, complete all relevant information and check the appropriate boxes. This includes tumor type, date of diagnosis, selecting applicable radiotracers, confirming cancer diagnosis, and providing patients' treatment history.
7. Elucidate the reasons for the study by selecting all applicable options regarding treatment types, response to therapy, and prior imaging results.
8. Finally, review the information entered for accuracy, save your changes, and choose to download, print, or share the form as needed.

Complete your documents online with confidence and ensure all necessary steps are taken for your PET CT prior authorization.