CMS-10152 PET Completion Form

PET Completion Form

National Oncologic PET Registry F-18 Fluoride PET Scan

• 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.)

1. 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:

ClinicalTrials.gov Identifier NCT00868582 Version: January 05, 2012 (Page last revised January 05, 2012)