Get Ct Low Dose Lung Cancer Screening Order Form

Filling out the CT Low Dose Lung Cancer Screening Order Form online is a vital step in facilitating an important health screening. This guide outlines clear and concise instructions to assist users in completing the form efficiently and accurately.

Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to access the CT Low Dose Lung Cancer Screening Order Form and open it in your preferred editor.
2. Enter the patient’s legal name in the designated field, ensuring it is printed clearly.
3. Provide the patient's date of birth in the appropriate format.
4. Input the physician's name in the corresponding field, also printed clearly.
5. Fill in the best contact number for the patient.
6. Select either 'Initial Screening' or 'Subsequent Screening' by marking the appropriate option.
7. Enter the referring physician’s NPI number for proper identification.
8. Specify the appointment date by filling in the designated date field.
9. Indicate the appointment time in the provided area.
10. Detail the smoking history by entering the pack-year amount, which is the number of packs smoked per day multiplied by the total number of years.
11. Choose the requested exam type, confirming it is 'CT Low Dose Lung Screening (without contrast)'.
12. Make sure the patient meets all the screening criteria listed, including age and smoking history requirements.
13. If applicable, review and note any exclusion criteria that may disqualify the patient from screening.
14. At the end of the form, ensure to complete the 'Ordering Physician Attestation' section by providing your name and signature along with the date.
15. Finalize the process by saving the changes, downloading, printing, or sharing the form as required.

Complete the CT Low Dose Lung Cancer Screening Order Form online today to ensure timely processing.