CMS-10152 NOPR_PET_report_submission_form

PET Report Submission Form
National Oncologic PET Registry
•

This form is used to transmit the PET Report. It is completed by the PET facility via Web-based data entry within 30
days of completing the PET scan.

PET FACILITY ID #: __________________
REGISTRY CASE #: __________________
1. DATE SCAN COMPLETED: _____/_____/_____
2. DATE PET REPORT COMPLETED: _____/_____/_____
3. INTERPRETING PHYSICIAN INFORMATION - Pull Down Menu of Facility’s Interpreting Physicians
4. PET REPORT (you must either attach a report file OR enter the report as free text)
Note that, if both a body PET study and a dedicated brain PET study were performed and reported
separately (rather than in a combined, single report), both reports should be submitted. If you are submitting
a PDF or JPEG file, both reports must be combined into a single file.
Attached:

PDF

JPEG
Or

Free Text Entry – if checked enter text here:
(cut & paste from Microsoft Word document or other text document)

5. AFTER BEING GIVEN THE NOPR PATIENT INFORMATION STATEMENT, DID THE
PATIENT CONSENT TO HAVE HIS OR HER DATA USED FOR NOPR RESEARCH?

YES

NO

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

Date

(auto filled)

Version: 05/24/07