PET Order Form - Fox Chase Cancer Center - fccc 2026

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The document is a Medical Necessity Form for ordering PET/CT scans, detailing various exam types, diagnoses, and the required information for medical justification. It includes sections for patient details, specific areas of interest, recent treatments, and a declaration of necessity by the physician.

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Click ‘Get Form’ to open the PET Order Form in our editor.
Begin by entering the Patient Name and MR # at the top of the form. These fields are essential for identifying the patient.
In the 'EXAM REQUESTED' section, check one option that best describes the type of PET/CT scan needed.
Next, indicate the purpose of the scan in the 'PET/CT IS BEING REQUESTED TO' section by checking one box.
Fill out the 'DIAGNOSIS' section by selecting one diagnosis from the provided options. Ensure accuracy as this is crucial for medical necessity.
Complete any additional information required, such as pertinent x-ray details and specific areas of interest.
Finally, have the physician sign and date at the bottom of the form to attest to its accuracy before submission.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Does a PET scan tell you the stage of cancer?

As Cancer Center Director at Fox Chase Cancer Center, Jonathan Chernoff works with Temple University Health System and Temple University peers to lead Fox Chase into the future of cancer care.

Is Fox Chase a good cancer center?

Yes, Fox Chase Cancer Center is ranked nationally by US News. Review their rankings and ratings at US News.

What diagnosis can be made with a PET scanner?

A PET-CT scan is usually used to help diagnose a range of different cancers, to find out how far they have spread and to decide the best ways of treating them. It gives detailed information about how well parts of your body are working as well as showing the areas that have been affected by disease.