Fillable Cardiac Nuclear Imaging Request - Pre-Op Cardiac Evaluation (eviCore)

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Cardiac Nuclear Imaging Request - Pre-Op Cardiac Evaluation (eviCore)

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The Cardiac Nuclear Imaging Request - Pre-Op Cardiac Evaluation (eviCore) form is 4 pages long and contains:

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  • 119 other fields

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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:
78451 78452 78453 78454 78466
78468 78469 78472 78473 78481
78483 78494 78496 78499 Other:
Diagnosis, if known or rule out:
ICD-10 Codes:
Date of last visit: Retro date of service:
Page 1 of 4
Cardiac Nuclear Imaging Request - Pre-Op Cardiac Evaluation
Patient/Member
Home Phone:
Ordering Provider
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.
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
60 days or less No documented contact
More than 60 days Don't know
2. Type of most recent documented contact with physician?
Hospital None
Office visit Don't know
Phone call
3. Is there a documented history of coronary artery disease?
Yes Don't know
No
No imaging stress test has ever been done 2 to 5 years ago
Less than 1 year ago More than 5 years ago
1 to less than 2 years ago Don't know
5. What type of surgery is going to be performed?
Open carotid endarterectomy (not stenting)
Breast surgery
Head and neck surgery
Open (not arthroscopic) orthopedic surgery
Open (not robotic or laparoscopic) prostate surgery
Procedure using endoscopy
Superficial/skin procedure
Cataract surgery
Ambulatory (outpatient or same day ) surgery
Laparoscopic, endovascular, or robotic surgery
Don’t know
Page 2 of 4
4. When was the most recent imaging stress test performed (example: nuclear stress test, stress echo, or stress
MRI)?
Open (not endovascular) surgery on the aorta, major open vascular surgery, or open peripheral
vascular surgery
Clinical Information
1. Date of most recent office visit or other documented contact with physician:
eviCore healthcare | www.eviCore.com | 400 Buckwalter Place Blvd • Bluffton, SC • 29910 | 800.918.8924
6. What symptoms are present?
No symptoms (asymptomatic)
Symptoms are present but stable )
New or worsening angina or angina equivalent
New or worsening atypical chest pain
Syncope
Documented ventricular tachycardia (VT)
None of the above
Don’t know
New or worsening heart failure
7. What level of exercise can this individual do?
Able and willing to exercise on a treadmill
Able but unwilling to exercise on a treadmill
Unable to exercise on a treadmill due to neurologic reason (CVA/stroke)
Unable to exercise on a treadmill due to orthopedic/musculoskeletal limitations
Severe COPD such as emphysema
None of the above
Don’t know
8. If exercise on a treadmill is not possible, please explain why: N/A
9. Had an ECG been done in the last 60 days?
Yes Don't know
No
10. What were the results of an ECG done within the last 60 days?
An ECG was not done within the last 60 days
Normal ECG
Nonspecific ST-T wave changes
Complete LBBB (Left Bundle Branch Block)
RBBB (Right Bundle Branch Block)
LVH with early repolarization
T-wave inversion in the inferior and/or lateral leads
WPW/pre-excitation
Hemiblock
Ventricular pacemaker
Digoxin effect
Other:
None of the above
Don’t know
Page 3 of 4
Clinical Information
Poor exercise tolerance (unable to walk at least 2 flights of stairs or 4 blocks on level ground without
stopping)
eviCore healthcare | www.eviCore.com | 400 Buckwalter Place Blvd • Bluffton, SC • 29910 | 800.918.8924
11. Which cardiac risk factors does the individual have? Select all that apply.
Diabetes Obesity
High blood pressure Cerebrovascular disease (TIA, stroke)
Hyperlipidemia (high cholesterol, etc) None of the above
Smoker Don’t know
Obstructive Sleep Apnea
12. Which clinical risk factors relating to surgical risk does the individual have? Select all that apply.
History of coronary artery disease (CAD) Cerebrovascular disease (TIA, stroke)
History of congestive heart failure (CHF) None of the above
Diabetes Don’t know
Chronic renal insufficiency with a creatinine greater than 2.0 mg/dl
Yes Don't know
No
14. Does this individual have a history of a false positive Exercise Treadmill stress Test?
Yes Don't know
No
15. Is there a personal history of cancer?
Yes Don't know
No
Additonal information/comments:
Who is making this request? Ordering Physician Facility Other:
Print Name:
Title: MD RN LPN PA NP Other:
Signature: Date:
Page 4 of 4
Submitter
13. Is this study being requested because there was a recent abnormal or equivocal Exercise Treadmill Stress
Test (ETT)?
Clinical Information
eviCore healthcare | www.eviCore.com | 400 Buckwalter Place Blvd • Bluffton, SC • 29910 | 800.918.8924
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Cardiac Nuclear Imaging Request - Pre-Op Cardiac Evaluation (eviCore)

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Completed 5 April 2022

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