Get Cardinal Health 7mc5579 2010-2026

The Cardinal Health 7MC5579 is a physician request form for oncologic PET/CT imaging. This guide will walk you through each section of the form to ensure you complete it accurately and efficiently.

Follow the steps to complete the form online confidently.

1. Click ‘Get Form’ button to obtain the form and open it in the designated online editor.
2. Enter the facility name, address, phone number, and logo in the designated fields at the top of the form.
3. Fill in the patient information section with the first name, last name, date of birth, phone number, and social security number as required.
4. Provide the name and phone number of the insurance company, along with the subscriber's insurance ID and prior authorization number.
5. Indicate the test date and test time, and fill in the referring physician's details, including their first name, last name, phone number, fax number, and signature (note that a stamp is not acceptable).
6. Record the physician's NPI number and date in the appropriate fields.
7. Complete the additional information section, including the patient's sex, weight, and diabetic status. Also, provide any relevant patient history and physician progress notes.
8. Indicate if the patient is pregnant or if nursing by checking the appropriate boxes.
9. Detail the clinical history and type of scan requested, including specific signs, symptoms, diagnosis, and ICD-9 code.
10. Select the type of scan requested by checking the corresponding box: standard body scan or special body scans.
11. Fill in the cancer type if applicable, including any Medicare covered oncology indications.
12. Complete any limitations that apply, if relevant, and if NOPR is applicable, attend to the required sections.
13. Indicate if ordering a diagnostic CT in conjunction with the PET exam and check the relevant boxes.
14. Review all entered information for accuracy and completeness.
15. Once all fields are completed, you can save changes, download, print, or share the form as required.

Complete your Cardinal Health 7MC5579 form online today to streamline your oncologic imaging requests.