Form CMS-10152 NOPR case_registration

Case Registration Form
National Oncologic PET Registry
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This form will be completed by the PET facility via Web-based data entry.
The PET scan and the Pre-PET form must be completed within 2 weeks of registering the patient. The pre-PET form
must be completed (and data entered on the Registry web site) no earlier than 2 weeks before the PET scan and no
later than midnight on the day of the PET scan
Upon form completion a case number will be assigned.
The referring clinician may elect to complete and submit the Pre-PET Form at the time of referral. If the clinician did
not submit a Pre-PET Form with the referral, a case specific Pre-PET Form will be sent electronically with the e-mail
confirmation of case registration to the PET facility for delivery to the referring physician.

PET Facility Log-in Info (facility ID# & password):
1. PATIENT INFORMATION
Date: _____/_____/_____
First Name: ________________

Last Name: __________________

Date of Birth _____/_____/_____
SSN#: __________________
Gender:
Male

Female

Ethnicity:
Hispanic

Not Hispanic

Unknown [Note: “Hispanic” is defined as a person of
Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.]

Race:

(must check one)

Asian

Black or African American

White or Caucasian

Other

Unknown

Patient’s 5-Digit Zip Code (if outside the U.S. enter 00000): ___ ___ ___ ___ ___
2. REFERRING PHYSICIAN INFORMATION
UPIN#: _________________
First Name: ________________ Last Name: __________________
Office Telephone: (____) _________________ Office Fax: (____) _________________
3. HAS THE PRE-PET FORM BEEN COMPLETED?
(if Yes is checked the PET facility will not be E-mailed a Pre-PET form to complete)

Yes

No

4. PATIENT IS SCHEDULED TO HAVE A PET SCAN ON: _____/_____/_____
(must be within 14 days of registration)

5. NAME OF PERSON SUBMITTING THIS FORM
First Name: ________________ Last Name: __________________

Date:
Version: 02/01/07