CMS-10152 Case Registration Form

[0938-0968 FORM #2]
Case Registration Form
National Oncologic PET Registry
PET Facility log-in information (facility ID, password): ______________________________________________________

1. PATIENT INFORMATION
Date:

Social Security #:

Last name: ________________________________
Date of Birth:

Gender:

 Male
 Female

First name: _____________________________________
Patient's Zip Code:

Ethnicity:

 Hispanic
 Not Hispanic
 Unknown

Race:

 Asian
 Black or African
American

 White or Caucasian
 Other
 Unknown

2. REFERRING PHYSICIAN INFORMATION
UPIN #: __________________________________

or

NPI #: ____________________________________

Last name: ________________________________

First name: _____________________________________

Office Telephone:

Office Fax:

 Yes
 No
(if Yes is checked the PET facility will not be E-mailed a Pre-PET form to complete)

3. HAS THE PRE-PET FORM BEEN COMPLETED?

4. DATE PATIENT SCHEDULED FOR PET SCAN?
(Must be within 14 days of registration.)

5. NAME OF PERSON SUBMITTING THIS FORM

Last name: _________________________

First name: ______________________

Date:

PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this
information collection is 0938-0968. The time required to complete this information collection is estimated
to average five (5) minutes per response, including the time to review instructions, search existing data
resources, gather the data needed, and complete and review the information collection. If you have
comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please
write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05,
Baltimore, Maryland 21244-1850.