Provider Referral - Testing Patient Name* First Last Date of Birth* Patient Phone Number*Appointment Date/TimeDiagnosisPerson Completing FormTestingUpload OrderMax. file size: 256 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 SpecifyVascular 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 SpecifyNotesPlease fax results toProviders Printed Name First Last Date Insurance InfoInsurance Type No Insurance/Self Pay Insurance Insurance Name*Subscriber Name* First Last Subscriber DOB* Member ID*Group #*Reason for ReferralPrior Authorization #No Authorization I do not require prior authorization Cardiologist ChoiceFirst AvailableAyalaBajwaKoduriKorpasMartinMentzerNetzRundlettAdditional Information Δ
