Get the free FORM: 85 - MAMMOGRAM Version: Description: When used ... - whi

WHO Volume 3, Form 85 Mammogram (Very. 3.1) FORM: 85 MAMMOGRAM Version: 3.1 February 17, 1995, Description: Completed by Clinic Practitioner (CP); 1page form; key entered at Clinical Center (CC).

How to fill out form 85 - mammogram

How to fill out form 85 - mammogram:

1. Start by providing accurate personal information in the designated fields, such as your full name, date of birth, and contact details.
2. Indicate the date on which you plan to have or have had the mammogram done.
3. Check the appropriate box to indicate whether it is your initial screening mammogram or a follow-up examination.
4. If you are a Medicare beneficiary, make sure to provide your Medicare number.
5. Specify the name and address of the facility where the mammogram will take place.
6. If you are enrolled in a health maintenance organization (HMO), include any relevant information regarding referral or authorization.
7. Sign and date the form to certify the accuracy of the provided information.

Who needs form 85 - mammogram?

1. Women who are scheduled to undergo a mammogram for breast cancer screening or diagnostic purposes generally need to fill out form 85 - mammogram.
2. Individuals who are Medicare beneficiaries and plan to have a mammogram should also complete this form.
3. If you are a member of a health maintenance organization (HMO) and require a referral or authorization for the mammogram, you will likely need to provide this form as well.

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What is form 85 - mammogram?

Form 85 - mammogram is a medical imaging procedure that uses low-dose X-rays to detect signs of breast cancer.

Who is required to file form 85 - mammogram?

Form 85 - mammogram is typically filed by individuals who are recommended to undergo regular mammogram screenings, such as women over a certain age or those with an increased risk of breast cancer.

How to fill out form 85 - mammogram?

Form 85 - mammogram is typically filled out by a healthcare provider who performs the mammogram procedure. The form will include details about the patient, the date of the procedure, and any relevant findings or recommendations.

What is the purpose of form 85 - mammogram?

The purpose of form 85 - mammogram is to document the results of a mammogram screening, including any abnormalities or concerns that may require further evaluation.

What information must be reported on form 85 - mammogram?

Form 85 - mammogram should include the patient's personal information, the date of the mammogram, the results of the screening, and any recommendations for follow-up care.