CMS-10152 PET Facility log-in information

(CMS-10152) Data collection for Medicare Beneficiaries Receiving FDG Positron Emission Tomography (PET) for Brain, Cervical, Ovarian, Pancreatic, Small Cell Lung, and All Other Cancers

Form 1

Collection for Medicare Bene#s Receiving FDG Positron Emissions Tomography for Brain, Cervical, Ovarian, Small Cell Lung, and Testicular Cancers

OMB: 0938-0968

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PET Facility log-in information (facility ID, password):


  1. PATIENT INFORMATION

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Date: Social Security #:


Last name: First name:


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Date of Birth: Patient's Zip Code:

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Gender:

  • Male

  • Female

Ethnicity:

  • Hispanic

  • Not Hispanic

  • Unknown

Race:

  • Asian

  • Black or African American

  • White or Caucasian

  • Other

  • Unknown



  1. REFERRING PHYSICIAN INFORMATION

UPIN #: or NPI #:


Last name: First name:


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Office Telephone: Office Fax:




  1. HAS THE PRE-PET FORM BEEN COMPLETED? Yes No

(if Yes is checked the PET facility will not be E-mailed a Pre-PET form to complete)




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  1. DATE PATIENT SCHEDULED FOR PET SCAN?

(Must be within 14 days of registration.)




  1. NAME OF PERSON SUBMITTING THIS FORM

Shape10 Last name: First name: Date:

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


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleAppendix B-II
Authorjulie
File Modified0000-00-00
File Created2021-01-23
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