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CT Low Dose Lung Screening Request Form

WHY ARE YOU BEING ASKED TO COMPLETE THIS REFERRAL REQUEST FORM?

The Affordable Care Act (ACA) requires that private insurers cover medical exams (including CT lung cancer screening) from the USPSTF without a co-pay. Imaging Healthcare Specialists is proud to be an ACR Designated CT Lung Cancer Screening Center and is required to obtain specific information for your patient prior to scheduling. We Thank You in advance for completing this important patient health history information so we may ensure your patients exam is covered under their current insurance plan.

The Centers for Medicare & Medicaid Services (CMS) has determined that the evidence is sufficient to add a lung cancer screening counseling and shared decision making visit, and for appropriate beneficiaries, annual screening for lung cancer with low dose computed tomography (LDCT), as an additional preventive service benefit under the Medicare program only if all required criteria are met.

Written orders for both initial and subsequent LDCT lung cancer screenings must contain the following REQUIRED information, including the physician/provider Statement (below) that the patient/beneficiary is asymptomatic (has no signs or symptoms of lung cancer); which must also be appropriately documented in the beneficiary’s medical records.

Criteria Required for Low Dose Lung Screening:

      Screening for patients age 55-77
      Minimum "30 Pack Year" smoker
      Less than 15 years since quitting
      Patient must be asymptomatic
 

Pack Year Examples:
1 pack/day X 10 years = 10 pack year*
3 packs/day x 10 years = 30 pack year

*Does not meet screening criteria



CT Low Dose Lung Screening (CPT-G0297) - All items with * are required.




Patient Information - All items with * are required.

Person Completing Form: Order must be initiated from a referring physician, PATIENT SELF-REFERRALS ARE NOT ACCEPTED

 

 

 
*Patient does not meet the requirements for the screening test.
*Patient does not meet the requirements for the screening test.
 
 

*Patient does not meet the requirements for the screening test.

Physician Information - All items with * are required.


 

 

BY MY ELECTRONIC SIGNATURE, I CERTIFY THAT MY PATIENT: *

  • has participated in a shared decision making session during which potential risks/benefits of CT lung screening were discussed
  • was informed of the importance/adherence to annual screening, impact of comorbidities, and ability/willingness to undergo diagnosis and treatment
  • was informed of the importance of smoking cessation and/or maintaining smoking abstinence,including the offer of Medicare-covered tobacco cessation counseling services, if applicable
  • is asymptomatic (no symptoms such as fever, chest pain, new shortness of breath, new/changing cough, coughing up blood, or unexplained significant weight loss)