 |
| Ordering Physician Information |
|
 |
Name |
|
|
Date |
|
|
Contact information |
|
|
Signature |
|
|
Initial Diagnosis |
| |
| Patient Information |
|
|
Patient Name |
|
|
Date of Birth |
|
|
Social Security Number |
|
|
Weight |
|
|
Diabetic - Yes or No |
|
|
Insurance and Authorization Number |
| |
| Type of Study |
|
|
Whole Body PET |
|
|
Select Approved Indication |
| |
| Previous Procedures
Including Date and Location Performed |
|
|
MR |
|
|
CT |
|
|
US |
|
|
PET/Nuclear Medicine |
|
|
Other |
| |
|
| Reimbursement/Coverage
Criteria |
|
|
Coverage criteria information is available
from our Reimbursement webpage. |
|
