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PET/CT PRESCHEDULING FORM ARA SCHEDULING: 512.458.9098 fax: 512.836.8869 PATIENT INFORMATIONREFERRING INFORMATIONName:Referring clinician signature:Date of birth:___ ___Phone:SignatureHeight:Phone:Alternate:Weight:Fax:Insurance
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How to fill out pylarify petct order form
How to fill out pylarify petct order form
01
Obtain the pylarify PET/CT order form from the ordering physician or imaging facility.
02
Fill out patient demographics including name, date of birth, and contact information.
03
Provide relevant medical history and reason for ordering the pylarify PET/CT scan.
04
Include insurance information and any relevant authorizations or referrals.
05
Ensure all sections of the form are completed accurately and legibly.
06
Submit the completed form to the imaging facility or ordering physician for processing.
Who needs pylarify petct order form?
01
Patients who have been prescribed a pylarify PET/CT scan by their physician.
02
Physicians who are ordering a pylarify PET/CT scan for their patients.
03
Imaging facilities that require a completed order form before scheduling a pylarify PET/CT scan.
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What is pylarify petct order form?
The Pylarify PET/CT order form is a document used to request a Positron Emission Tomography/Computed Tomography scan using the radiopharmaceutical Pylarify, which is often utilized for imaging in certain oncological indications.
Who is required to file pylarify petct order form?
Healthcare providers such as physicians, radiologists, or oncologists who are prescribing the Pylarify PET/CT scan are required to fill out and file the order form.
How to fill out pylarify petct order form?
To fill out the Pylarify PET/CT order form, the healthcare provider must include patient information, clinical indications for the scan, necessary approvals, and any specific instructions related to the imaging procedure.
What is the purpose of pylarify petct order form?
The purpose of the Pylarify PET/CT order form is to formally request the imaging procedure and ensure that all necessary patient information and clinical indications are documented for proper coordination and billing purposes.
What information must be reported on pylarify petct order form?
The Pylarify PET/CT order form must report the patient's identification details, clinical history, symptoms leading to the referral, insurance information, and other necessary medical records relevant to the scan.
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