Get the free LDCT Lung Screening Order Form 1.docx

CONE CT LUNG CANCER SCREENING ORDER FORM 1221 Pine Grove Avenue Port Huron, Michigan 48060 Phone (810) 9893270 Fax (810) 9876342 Patients Name: DOB: (First)(Middle Initial)Home Phone: (Last)Cell Phone:

How to fill out ldct lung screening order

How to fill out ldct lung screening order

1. To fill out an LDCT lung screening order, follow these steps:
2. Gather all the necessary information, such as the patient's name, date of birth, and contact information.
3. Make sure you have the appropriate referral information, including the referring physician's name, contact details, and NPI number.
4. Verify that the patient meets the eligibility criteria for LDCT lung screening, which typically includes being between 55 and 80 years old, having a history of smoking for at least 30 pack-years, and being a current smoker or having quit within the last 15 years.
5. Consult the specific requirements of the healthcare institution or insurance provider for any additional information that needs to be included on the order form.
6. Fill out the LDCT lung screening order form accurately and legibly, providing all the required information.
7. Sign and date the order form, ensuring it is properly authorized.
8. Submit the completed LDCT lung screening order form to the appropriate department or healthcare provider as per the institution's guidelines.

Who needs ldct lung screening order?

1. The LDCT lung screening order is typically needed for individuals who meet the eligibility criteria for LDCT lung screening.
2. This usually includes individuals who:
3. - Are between 55 and 80 years old
4. - Have a history of smoking for at least 30 pack-years (packs smoked per day multiplied by the number of years smoked)
5. - Are either current smokers or have quit smoking within the last 15 years
6. However, it is important to consult with a healthcare professional or the specific requirements of the institution or insurance provider to determine who specifically needs an LDCT lung screening order in a given context.

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