Providence Imaging Center PET-CT Requisition Form

Submit the completed PET-CT Requisition Form to Providence Imaging Center. You can fax the form to (907) 212-5828 or send it via mail to 3340 Providence Drive, Anchorage, AK 99508. For any inquiries, contact the center directly at (907) 212-2879. Ensure all information is accurately filled in and the form is signed by the referring clinician before submission. Additionally, make arrangements to forward copies of relevant imaging studies and reports to the imaging center. Timely submission of the form helps facilitate prompt scheduling and processing of the PET-CT scan.

No specific dates are provided for 2024 and 2025. Ensure that you have all necessary information and signatures before submitting the form.

The purpose of this PET-CT Requisition Form is to facilitate the request for PET-CT scans at Providence Imaging Center. It collects essential patient information, clinical history, and details about recent imaging studies to ensure accurate and timely imaging services. Clinicians use this form to provide necessary information that supports ICD-10 codes and guides the imaging process. Accurate completion of this form is critical for proper diagnosis, staging, and monitoring of various medical conditions, including cancer. By including detailed clinical terms, history, and symptoms, healthcare providers can ensure the appropriateness and necessity of the imaging study. This helps in coordinating care and avoiding unnecessary delays in patient management. Furthermore, the form also outlines special accommodations required by the patient, ensuring their comfort and safety during the imaging procedure. By diligently filling out this form, healthcare providers can guarantee that all relevant information is communicated to the imaging center, leading to optimal patient care and successful imaging outcomes.

• 1. Patient's Last Name: Enter the patient's last name.
• 2. First Name: Enter the patient's first name.
• 3. Date: Enter the date of form completion.
• 4. Date of Birth: Enter the patient's date of birth.
• 5. Home Phone: Enter the patient's home phone number.
• 6. Work Phone: Enter the patient's work phone number.
• 7. Gender: Select the patient's gender (male or female).
• 8. Cell Phone: Enter the patient's cell phone number.
• 9. Referring Clinician: Enter the name of the referring clinician.
• 10. Height: Enter the patient's height.
• 11. Weight: Enter the patient's weight.
• 12. Send Additional Copies of Report To: Specify additional recipients for the report.
• 13. Clinical terms/history/symptoms: Include specificity requirements that support ICD-10 codes.
• 14. ICD-10 codes: Enter the ICD-10 codes that support clinical history and symptoms.
• 15. Diabetic?: Indicate if the patient is diabetic and insulin-dependent.
• 16. Special Accommodations: List any special accommodations the patient may need.
• 17. PET-CT Fusion Scan: Select the type of PET-CT scan required.
• 18. Reason for Scan: Specify the reason for the scan (e.g., initial staging, diagnosis).
• 19. Treatment: Indicate if the patient is currently undergoing treatment and type.
• 20. Date and Location of Recent Imaging Studies: Provide details about recent imaging studies.
• 21. Clinician Signature: Sign the form as the referring clinician.

Failure to submit this form may result in delays or cancellation of the PET-CT scan. This may affect the diagnosis, staging, and treatment monitoring for the patient.

• Delay in Diagnosis: Without the form, the imaging appointment may be delayed, potentially affecting timely diagnosis.
• Treatment Delays: Failure to submit may cause delays in treatment planning and monitoring.
• Insurance Issues: Incomplete submissions may result in insurance claim denials or delays.

• 1. PET-CT Scan Request: When a PET-CT scan is needed for diagnosis, staging, or monitoring.
• 2. Clinical History Documentation: To document clinical terms and symptoms supporting the need for imaging.
• 3. Patient Information Submission: To provide necessary patient details for the imaging appointment.
• 4. Insurance Processing: To ensure proper coding and support for insurance claims.
• 5. Coordination of Care: To facilitate communication and care coordination between healthcare providers and the imaging center.