1. ORDER FORM
Procedure Name and CPT Code
- 78814 – Beta-Amyloid Scans
- 78815 – Standard Body (most commonly used)
- 78816 – Whole Body (primarily used for melanoma, sarcoma, PET bone scan, etc.)
- 78608 – Metabolic Evaluation of the Brain
Primary Diagnosis Code
- ICD – 10 only
- Select code most specific to patient’s condition AND location/area of the body
- Clinical indications for scan (diagnosing, staging, restaging, treatment monitoring or radiation treatment planning)
- If indication is not pathology proven, please note the clinical signs and symptoms to support the reason for the scan
Provider Signature/NPI Number
Date/Time of Patient’s Follow Up
2. PATIENT’S DEMOGRAPHICS
3. PATIENT’S INSURANCE CARD
- Primary and secondary insurance, if applicable
- Front and back
4. CLINICAL NOTES
- Most recent provider note
- Recent imaging (please have patient bring CD, if available)
- Pathology, if applicable
