Authorization
For Positron Emission Tomography (P.E.T.) Scan
Dear Patient:
Positron Emission Tomography is a very useful diagnostic procedure. However, since it is
relatively new technology some insurance plans may not cover the service. Your insurance
carrier may consider this procedure to be “investigational” or a “non-covered” service in some
cases. Some plans may require the establishment of “medical necessity” before the procedure
will be paid. Predetermination of coverage may result in a time delay. We will make every
reasonable effort to obtain prior authorization for your exam, and perform the scan as ordered by
your physician within the timeframe requested. You will be responsible for payment in the event
your insurance carrier denies coverage. We appreciate your understanding.
_____ BRAIN – Metabolic / Oncologic
_____ ONCOLOGY – Whole Body
_____ Cardiac – Viability
Patient Agreement:
I have been notified by Valley Diagnostic Imaging Services, Valley Medical Center and Valley
Radiologists staff that my insurance company may deny payment for the services identified
above.
I agree to be fully and personally responsible for payment.
Patient name (please print):______________________________________________________
Patient
signature:__________________________________________Date:__________________
Legal
Guardian:___________________________________________Date:__________________
Witness:____________________________________________Date:_________________
Olympic Building  400 South 43rd Street  Renton, Washington 98055  425-656-5550 Ph.  877-674-2674 Toll-free  425-656-5552 Fax
(Valley Radiologists Inc., P.S. in association with Valley Medical Center)
Welcome to Valley Diagnostic Imaging,
We have attached preparation instructions for you to follow to get the best results from
your scan. Please review this packet a few days before your appointment date to make sure
you start your prep on time. If you have any concerns about your scan, billing or
preparation instructions feel free to call the imaging center.
PET exams are performed at 4033 Talbot Rd. S, Ste. 360, Renton, WA 98055. Please
check-in at this location.
Olympic Building  400 South 43rd Street  Renton, Washington 98055  425-656-5550 Ph.  877-674-2674 Toll-free  425-656-5552 Fax
(Valley Radiologists Inc., P.S. in association with Valley Medical Center)