CMS-10152 Report Submission Form

[0938-0968 Form #5]
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. INTERPETING PHYSICIAN INFORMATION

Pull Down Menu of Facility’s

Scanner Info

4. PET REPORT (You must either attach a report file in PDF or JPEG format OR enter the report as
free text. No other file formats are accepted.)

Free text entry is preferred.
Note that, if both a body PET study and a dedicated brain PET study were performed and reported
separately (rather than in a combined report), both reports should be submitted. If you are submitting as
PDF or JPEG, you must combine all all reports into a single file.

a. Attachment
 PDF
 JPEG
OR
b. Free text
Cut and paste from Microsoft Word document or other text document. You must enter the

complete text of the PET report, pasting or typing all pages.

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.