Patient Referral Form For The Cardiology Center

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Patient Name_________________________________
Date of Birth_________________________________
Phone Number________________________________
Please Fill in or Affix a Patient Label
Cardiology Center Referral Form
Patient Information
___________________________________________
______________________
(First, Last) ame
DOB
___________________________________
___________ ______ __________
Mailing Address
City
State
Zip
___________________________________
______________________________
Patient Phone #
Secondary #
___________________________________
______________________________
Primary Insurance
Secondary Insurance
________________________________________________________
Referring Provider:
____________________________________________________
Diagnosis Code(s) ICD-10:
Appointment Type
New Patient Visit
24 Hour Holter Monitor/Zio Patch Holter
Pre-Op Appointment
48 Hour Holter Monitor/Zio Patch Holter
Established Patient Visit
Zio Patch Extended 48 Hours to 14 Days (not for Medicaid or Humana)
Event Monitor
CV Mobile Telemetry (not for BCBS Members)
CPT Code for Testing (Check all that apply.)
CPT
Cardiology Tests
CPT
Echocardiography Tests
Treadmill Stress Test (Walking-nonnuclear)
Echo Complete
93017
93306
78452
Myoview Stress Test (Walking-nuclear)
93306
Echo Complete with Bubble Study
78451
Lexiscan / Myoview Stress Test (Resting Nuclear)
93308
Echo Bubble Only
78453
Dobutamine / Myoview Stress Test
93308
Echo Limited
Pulmonary / Metabolic Exercise Stress Test
Echo Stress (Dobutamine)
94621
93351
93005
EKG
93351
Echo Stress (Treadmill)
Other (Fill-in Test ame / CPT Code / ICD-10-CM Code.)
_________________________________________________________________________________________
_________________________________________________________________________________________
Pre-cert #: ____________________________________________________________
*Please ensure pre-cert # is provided (if required) prior to scheduling appointment.*
______________________
______________________
Date of Appointment:
Scheduled by:
_______________________
Informed Patient Date/Time:
_______________________________
______
______
Ordering MD Signature:
Date:
Time:
*Please ensure that all applicable records and most recent labs/tests are attached.*
*Must be signed by physician for EKG/Monitor, will not process without signature. *
175 Mary Street
Boone, C 2607
P: (828)264-9664
F: (828)264-8144
Page 1 of 1
Effective Date: 09/01/2010
Revised Date: 05/27/2016
Form Number: 11077

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