Lung Cancer Screening Request Form

To request a lung cancer screening, please provide your contact information and answer a few questions to see if you qualify.

Before you can have the screening, you’ll need to complete a counseling visit with a primary care provider. During this visit, you and your provider will discuss the screening and decide together if it’s right for you.

If you qualify, our Lung Screening Coordinator will help schedule this visit for you.

If you already have a primary care provider, we’ll work with them.
If you don’t have one, we’ll help you get set up with one of our Internal Medicine Residency Practice providers.

You must meet certain eligibility requirements to be scheduled for screening. The good news is that most insurance plans cover this service.

Full Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

example@example.com

Date of Birth

Date

Health Insurance Provider

Are you between the ages of 50 and 77?

Have you smoked at least 20 pack-years in your lifetime? (For example: 1 pack/day for 20 years, 2 packs/day for 10 years, etc.)

What is your current smoking status?

Are you currently experiencing any pulmonary symptoms (such as cough, shortness of breath, chest pain, or unexplained weight loss)?

Have you had a chest CT scan within the last year?

Do you have a primary care provider?

What is the name of your primary care provider?

We're sorry, based on your results you are not eligible for a lung cancer screening.

Who Is Eligible for Lung Screening?

LDCT lung screening is recommended for the following persons who are considered by medical professionals as being at “high risk” for developing lung cancer:

Ages 50-77 AND
A 20 or more pack a year or equivalent smoking historyone pack a day for 20 years, 2 packs a day for 10 years, ect.
Current smokers or former smokers who have quit smoking within the last 15 years
Currently showing no signs of pulmonary symptoms
No other chest CT within one year.

If you would like to discuss eligibility, please call our Lung Screening Coordinator at 812-885-3638.