PET Scan Order Criteria

Ordering Physician Information

• Name
• Date
• Contact Information
• Signature
• Initial Diagnosis

Patient Information

• Patient Name
• Date of Birth
• Social Security Number
• Weight
• Diabetic - Yes or No
• Insurance and Authorization Number

Type of Study

• Whole Body PET
• Select Approved Indication

Previous Procedures Including Date and Location Performed

• MR
• CT
• US
• PET/Nuclear Medicine
• Other

Reimbursement/Coverage Criteria

• Coverage criteria information is available from our PET Reimbursement Guide and Medicare Coverage Criteria Guide for PET for Alzheimer's Disease.