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When a patient undergoes a CT chest for nodule follow-up, the claim should show: Procedure: 71250 (CT chest without contrast) Linked diagnosis: R91.1 (solitary pulmonary nodule) This linkage demonstrates that the procedure was medically necessary based on the documented diagnosis

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Personal information (SSN, address, physical description) Criminal history disclosure (7 specific questions about tobacco-related offenses) Notarized affidavit (Section 4B) Section 6 Applicant Affidavit: The applicant must sign and notarize this section, agreeing to inspections and record-keeping requirements