Your Partner in Health Patient Scheduling

Low Dose Lung CT Screening Request

Patient Information - All items with * are required.

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

 

 

 

 

Physician Information - All items with * are required.


 

 

Procedures Request - Please mark/fill in all the procedures that apply*

Please select at least one procedure

CT Lung Screening

Other

Physician Verification - Please confirm the following conditions *

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