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LUNG CANCER SCREENING LOW DOSE CT (LCT) Order (Fax completed form to Pt Registration 3143980)Patient name: ___ DOB: ___ Ordering Physician: ______printed name of ordering providerSignatureOrdering

How to fill out low-dose-ct-lung-screening-order-form

How to fill out low-dose-ct-lung-screening-order-form

1. Obtain the low-dose-ct-lung-screening-order-form from a healthcare provider or facility.
2. Fill out the patient information section including name, date of birth, address, and contact information.
3. Provide information on the ordering healthcare provider such as name, NPI number, and contact information.
4. Indicate the reason for the low-dose CT lung screening and any relevant clinical history.
5. Sign and date the form to certify the accuracy of the information provided.

Who needs low-dose-ct-lung-screening-order-form?

1. Individuals who are at high risk for lung cancer as determined by their healthcare provider.
2. Individuals who meet the criteria for eligibility for low-dose CT lung screening as recommended by medical guidelines.

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What is low-dose-ct-lung-screening-order-form?

The low-dose CT lung screening order form is a medical document used by healthcare providers to order low-dose computed tomography (CT) scans for lung cancer screening in eligible patients.

Who is required to file low-dose-ct-lung-screening-order-form?

Qualified healthcare providers, such as physicians or nurse practitioners, are required to file the low-dose CT lung screening order form on behalf of eligible patients.

How to fill out low-dose-ct-lung-screening-order-form?

To fill out the low-dose CT lung screening order form, providers must complete sections that include patient demographics, clinical history, risk factors, and the specific details of the CT scan being requested.

What is the purpose of low-dose-ct-lung-screening-order-form?

The purpose of the low-dose CT lung screening order form is to ensure proper documentation and authorization for lung cancer screening, facilitating timely and appropriate care for patients at high risk.

What information must be reported on low-dose-ct-lung-screening-order-form?

The information that must be reported includes the patient's name, date of birth, medical history, smoking history, the reason for screening, and details of the referring provider.