CMS-10152 PET Completion Form

[0938-0968 Form #4]
PET Completion Form
National Oncologic PET Registry
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This form is completed by the PET Facility via Web-based data entry within 14 days of case
registration.
The PET scan must be completed within 14 days of case registration. If the case was registered
more than 14 days prior to the PET scan the patient must be re-registered. The original case
registration will be cancelled and the $50 will be refunded.

PET FACILITY ID #: _______________________________
REGISTRY CASE #: ______________________________

1. DATE SCAN COMPLETED:
(must be within 14 days of registration)

2. SCAN TYPE (you must check one)
 PET
 PET-CT

3. REGION(S) SCANNED (you must check only one)
 Limited Body Region
(Study will be billed using CPT Codes: 78811 or 78814.)

 Skull base to proximal thighs
(Study will be billed using CPT Codes: 78812 or 78815.))

 Whole-body (vertex to toes)
(Study will be billed using CPT Codes: 78813 or 78816.)

4. SCANNER INFORMATION
Facility’s Scanner Identifier (facility’s name for scanner) - Pull Down Menu of Facility’s
Scanner Info

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

Last 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.