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UR Medicine / Imaging / Physician Resources / Forms & Information Sheets

 

Forms & Information Sheets

To order patient information forms (CT, MRI, GI, IR, US, Nuclear Medicine) and/or Requisitions (ALL are 50 sheets/pad) please email scheduling_iscw@urmc.rochester.edu and provide the following information:

  • Name/Dept
  • Delivery Address
  • Name of Form
  • Number of Pads Requested

Please allow 1 week for delivery.

Requisitions

The USPSTF has expanded the recommended age range and pack-year eligibility criteria and now recommends annual screening for lung cancer with LDCT in adults aged 50 to 80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years. However, CMS and insurance companies have not yet updated their National Coverage Determination which prevents us from serving patients who would qualify under the new USPSTF recommendation at this time. Therefore the current qualifying guidelines for ordering Low Dose Lung Cancer Screening CT remain; ages 55-80 with a 30+ pack-year smoking history.

For more information, see the Final Recommendation Statement from the USPSTF.

Exam Information Sheets