Provider Referral - Testing Patient Name* First Last Date of Birth* MM slash DD slash YYYY Patient Phone Number*Appointment Date/Time Diagnosis Person Completing Form TestingUpload OrderMax. file size: 300 MB.Cardiology Incision check / status post device implant 2D Echocardiogram Limited Echocardiogram Echocardiogram with Bubble Study Echocardiogram with Strain Dobutamine Stress Echocardiogram Treadmill Stress Echocardiogram Routine Treadmill Lexiscan Cardiolite Treadmill Cardiolite Holter Monitor (24 hour) (48 hour) Event Monitor (7 days) (14 days) (30 days) Chest X-ray Device Check EKG Calcium Score CT Chest (with and without contrast) CT Abdomen/Pelvis (with and without contrast) CT Heart Morphology CTA Chest CTA Abdomen/Pelvis CTCA Other Please Specify Vascular Ankle Brachial Index Abdominal Duplex Limited Complete Arterial Duplex Carotid Duplex Venous Duplex PreVNUS Vein Mapping Please Select Unilat/Bilat Upper/Lower Please Select Limited Complete Labs CMP BMP CBC BNP FLP INR UA TSH Other Please Specify NotesPlease fax results to Providers Printed Name First Last Date MM slash DD slash YYYY Insurance InfoInsurance Type No Insurance/Self Pay Insurance Insurance Name* Subscriber Name* First Last Subscriber DOB* MM slash DD slash YYYY Member ID* Group #* Reason for Referral Prior Authorization # No Authorization I do not require prior authorization Cardiologist ChoiceFirst AvailableAyalaBajwaKoduriKorpasMartinMentzerNetzRundlettAdditional Information Δ
