Get the free CT Lung Screening Order Form - Premier Radiology

CT Lung Screening Order Form For insurance submission, screening criteria* and completed form are required. Patient Name: MAN: DOB: / / Packs×day (20 cigarettes×pack): x Years smoked: Pack years*:

How to fill out ct lung screening order

How to fill out CT lung screening order?

1. Obtain the necessary form: Locate the CT lung screening order form from your healthcare provider. This form may also be available online.
2. Personal information: Fill in your personal details such as your full name, date of birth, address, and contact information. Ensure that all the information is accurate and up to date.
3. Medical history: Provide relevant medical history, including previous lung conditions, smoking history, and any relevant allergies or medical conditions. This information is crucial for the healthcare provider to determine the appropriateness of the screening.
4. Referring physician information: Include the name, address, and contact information of the physician who is referring you for the CT lung screening. This allows for efficient communication and coordination of your healthcare.
5. Insurance information: If applicable, fill in your insurance details accurately. This may include policy numbers, group numbers, and contact information for the insurance provider. Make sure to bring your insurance card or any other necessary documentation to your appointment.
6. Patient consent: Read through the patient consent section carefully and provide your signature if you agree to undergo the CT lung screening. This ensures that you have understood the benefits, risks, and potential outcomes of the procedure.

Who needs CT lung screening order?

1. Current or former smokers: CT lung screening is often recommended for current or former smokers who meet certain criteria. This includes individuals between the ages of 55 to 80, who have a smoking history of 30 pack-years (smoking one pack per day for 30 years) or more.
2. Individuals at high risk: People with a history of heavy exposure to secondhand smoke or certain occupational exposures that increase the risk of developing lung cancer may also require a CT lung screening order.
3. Those with lung disease symptoms: Individuals experiencing certain symptoms such as persistent cough, shortness of breath, or chest pain may be advised to undergo a CT lung screening. This helps in diagnosing potential lung conditions early on.

It is important to consult with your healthcare provider to determine if you meet the criteria for a CT lung screening order. They will evaluate your individual risk factors and medical history to determine the appropriateness of the screening for you.

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What is ct lung screening order?

CT lung screening order is a physician's request for a CT scan of the lungs to check for signs of lung cancer.

Who is required to file ct lung screening order?

A healthcare provider, typically a physician, is required to file a ct lung screening order for a patient.

How to fill out ct lung screening order?

The healthcare provider must provide the patient's information, reason for the screening, and any relevant medical history on the ct lung screening order form.

What is the purpose of ct lung screening order?

The purpose of ct lung screening order is to detect lung cancer at an early stage when it can be more effectively treated.

What information must be reported on ct lung screening order?

The ct lung screening order must include the patient's name, date of birth, reason for screening, relevant medical history, and the healthcare provider's information.