Request For Fetal Echocardiogram
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1Fetal Cardiovascular Program
Anita Moon-Grady, MD
Phone: (415) 353-1887
Michael Brook, MD
Fax: (415) 502-0660
Mark Cocalis, MD
Shabnam Peyvandi, MD
Hythem Nawaytou, MBBCH
Request for Fetal Echocardiogram
Norman Silverman, MD
This form is for cardiac/echo referral only. Please send completed form along with a copy of the insurance card, authorization,
and clinical documentation by fax (415) 502-0660 or email fetalheart@ucsf.edu.
For additional Fetal Treatment services please contact the Fetal Treatment Center 1-800-RX-FETUS (1-800-793-3887).
Date of Referral
Obstetrical History
/
/
mm/dd/yyyy
G _____ P _____ TAB _____ SAB _____
IUFD _____
Patient Name
Last
First
Gestational Age Today _____ weeks _____ days
Date of Birth
/
/
mm/dd/yyyy
/
/
/
/
LMP
EDC
Patient Contact Info
mm/dd/yyyy
mm/dd/yyyy
Address
Diagnostic Tests Done
Check all that apply
City
State
Zip Code
None
Amnio
CVS
NIPT
Other
(
)
–
(
)
–
Home
Work
Results
(
)
–
Mobile
Primary OB
Kaiser MR#
Name
Last
First
(
)
–
(
)
–
Phone
Fax
Number of Fetuses
Singleton
Twin
Other multiple
MFM / Perinatologist
Indication for Referral
Name
Last
First
Increased NT ( ______ mm ) • O35.8XX0
Phone
(
)
–
Fax
(
)
–
Family History • O35.2XX0
including patient • O99.419, Q24.9
Submitting Office Contact
Diabetes (Type ___________________ ) • O24.919
Name
Last
First
Maternal SSA/SSB • O35.8XX0
(
)
–
Phone
Email
Fetal Arrhythmia • O76
Known Chromosome Abnormality • O35.1XX0
Insurance Preauthorization
ART/IVF __________________ • 135.8XX0
If your patient requires insurance preauthorization, please fax
or send the confirmation to us prior to the appointment date.
Other (Specify _______________________ ) • O35.8XX0
Fetal Echo & Consultation Codes:
76825, 76827, 76820, 93325, 99244
Additional Fetal Treatment Indications*
Twin Twin Transfusion Syndrome • O30.039, O43.029
UCSF Staff Only — Scheduling Triage
Suspected Abnormality of the Heart • O35.8XX0
EGA
13-14
18-24
other
Other Abnormalities (Specify ____________________ )
Location
FTC
PDC
either
* If your patient needs additional Fetal Treatment services
contact the Fetal Treatment Center at 1-800-RX-FETUS to
Duration
1
1.5
other
coordinate the fetal echo and other appointments.
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