Thelow dose CT (LDCT) scan is fully funded under Medicare however your doctor may charge a consultation fee for the request and any follow up required.
PATIENT DETAILS		
Patient name:  <<Patient Demographics:Full Name>>	Date of birth:  <<Patient Demographics:DOB>>	
Address::  <<Patient Demographics:Address>>	 Telephone (H): <<Patient Demographics:Phone (Home)>>  (m) <<Patient Demographics:Phone (Mobile)>>	
                   <<Patient Demographics:City>>  <<Patient Demographics:Postcode>>	 Medicare No:  <<Patient Demographics:Medicare Number>>	

 CLINICAL INFORMATION  (mark with X)	

	  This patient meets the eligibility criteria of the National Lung Cancer Screening Program	

Type of screening test:	

	  2 yearly scan: New participant      OR		 Participant returning for two-year scan	

            OR
	
	  Interval scan: to monitor previous findings (1,2,3,6,or 12 month scan as determined in previous NLCSP LDCT report)	

	  Any previous Chest CT: (if known) Date:	 	 Radiology/provider/location (if known)	 	

	  Family history of lung cancer in a first-degree relatives (only required for first/baseline LDCT) 	
	  (First-degree relatives include parents, siblings or children)	

	  History of any cancer  (if yes provide details)	 	

Additional clinica/other notes if required.

REFERRING DOCTOR DETAILS		
Name:   <<Doctor:Phone>>	Provider N.o.   <<Doctor:Provider Number>>	
Address::  <<Practice/Location:Name>> <<Doctor:Address>>	Telephone: <<Doctor:Phone>>	
                  <<Doctor:City>>  <<Doctor:Postcode>>	 Fax No:  <<Doctor:Fax>>	

Doctors Signature:	

Date: <<Miscellaneous:Date (short)>>	
Send copy to: 		

PATIENT SHOULD SIGN IN I-MED CLINIC WHEN THEY ATTEND THE APPOINTMENT	

 Are you the Assignor? 	¡   YES 	¡   NO

I assign my right to benefits to the diagnostic imaging provider who will
render the requested diagnostic imaging service/s and any eligible determinable service/s.	

Signature: 	

Date: 	

Your personal information, including results of low dose CT scans and other CT imaging completed for the purposes of screening as part of the NLCSP, may be shared between your treating healthcare providers for the purposes of the NLCSP. For example, if you attend different radiology providers for your first low-dose CT scan and your second low-dose CT scan, the first radiology provider may disclose your low-dose CT images to the second radiology provider to facilitate comparison of the results of the two low-dose CT scans. By participating in the NLCSP,you consent to the use of your personal information by healthcare providers, specialists and radiologists, for the purposes of the program, and the disclosure and collection of your personal
information between healthcare providers, specialists and radiologists for the purposes of the program.