Fillable Cardiac - TransEsophageal Echo Imaging Request (eviCore)

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Cardiac - TransEsophageal Echo Imaging Request (eviCore)

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The Cardiac - TransEsophageal Echo Imaging Request (eviCore) form is 2 pages long and contains:

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First Name: Middle Initial: Last Name:
DOB (mm/dd/yyyy ):
Gender: Male Female
Street Address: Apt #:
City: State: Zip:
Cell Phone:
Primary Contact: Home Cell
Health Plan: Member ID: Group ID:
First Name: Last Name:
Primary Specialty:
TIN: NPI:
Physician Phone: Physician Fax:
Address: Suite #:
City: State: Zip:
Office Contact: Ext:
Contact Email:
First Name: Last Name:
Group/Site Name:
Primary Specialty:
TIN: NPI:
Site Phone: Site Fax:
Address: Suite #:
City: State: Zip:
93312 Other:
93315
93318
Diagnosis, if known or rule out:
ICD-10 Codes:
Date of last visit: Retro date of service:
Page 1 of 2
Facility/Site
Procedure
Check all
applicable
CPT Codes:
Diagnosis
CONFIDENTIALITY NOTICE: This fax transmission, and any documents attached to it may contain confidential or privileged information subject to privacy
regulations such as the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This information is intended only for the use of the recipient
(s) named above. If you are not the intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby notified that any
disclosure, copying, distribution or use of any of the information contained in or attached to this transmission is STRICTLY PROHIBITED. If you have
received this transmission in error, please immediately notify eviCore healthcare and destroy the original transmission and its attachments without saving
them in any manner.
Ordering Provider
Patient/Member
Home Phone:
Cardiac - TransEsophageal Echo Imaging Request
For NON-URGENT requests, please fax this completed document along with medical records, imaging, tests, etc.
If there are any inconsistencies with the medical office records, please elaborate in the comment section. Failure to
provide all relevant information may delay the determination. Phone
request. authorization an submit to site the
on located portal provider the into log also may You section. Forms Fax and Guidelines the under eviCore.com
on found be can numbers fax and
URGENT (same day) REQUESTS MUST BE SUBMITTED BY
PHONE
eviCore healthcare | www.eviCore.com | 400 Buckwalter Place Blvd • Bluffton, SC • 29910 | 800.918.8924
Pre Cardioversion
Congenital Heart Disease
Valve Disease
Disease of aorta (aneurysm, dissection, etc.)
Emboli
Other:
Don’t know
2. When was the most recent prior TransThoracic Echo (TTE) performed?
No prior TTE
Less than 1 week ago
1 week to less than 1 month ago
1 month to less than 6 months ago
6 months to less than 1 year ago
1 year ago or greater
Don’t know
3. Was the TransThoracic Echo (TTE) difficult to perform or interpret? (Limited window, poor images, etc.)
No prior TTE Yes
No Don't know
Additonal information/comments:
Who is making this request? Ordering Physician Facility Other:
Print Name:
Title: MD RN LPN PA NP Other:
Signature: Date:
Page 2 of 2
Submitter
Clinical Information
1. What are the reasons for requesting TransEsophageal Echo (TEE)? Select all that apply.
eviCore healthcare | www.eviCore.com | 400 Buckwalter Place Blvd • Bluffton, SC • 29910 | 800.918.8924
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Cardiac - TransEsophageal Echo Imaging Request (eviCore)

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Completed 5 April 2022

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