Imaging Healthcare Specialists

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.

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

Type:* Initial Repeat Follow-up

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 First Name*

Patient Last Name*

Patient Phone*

Patient Date of Birth*

Current Patient Age*

Is patient asymtomatic?*
Yes No

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

Packs Smoked Per Day:*
Number of Years Smoked:*
(“Pack Year” Total)

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

Has patient stopped smoking?*
Yes No

If YES, did they stop smoking within the last 15 years?*
Yes No

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

Physician Information - All items with * are required.

Ordering MD/Provider*		National Provider Identifier (NPI)*
Physician Phone*		Physician Fax*

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)

CT Low Dose Lung Screening Request Form

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

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

Patient Information - All items with * are required.

Physician Information - All items with * are required.

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

Check this box to certify the above conditions have been met. *

Check this box to certify your electronic signature for this patient exam order. *