Fillable Stress Echo Imaging Request (eviCore)

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Stress Echo Imaging Request (eviCore)

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The Stress Echo Imaging Request (eviCore) form is 3 pages long and contains:

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  • 19 check-boxes
  • 122 other fields

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File type: PDF

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Stress Echo Imaging Request
First Name: Middle Initial: Last Name:
DOB (mm/dd/yyyy ):
Gender: Male Female
Street Address: Apt #:
City: State: Zip:
Home Phone: 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:
93350 93351 93352 Other:
Diagnosis, if known or rule out:
ICD-10 Codes:
Retro Date of Service:
Page 1 of 3
Patient/Member
Ordering Provider
Facility/Site
Check all
applicable CPT
Codes:
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.
Procedure
Diagnosis
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.
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URGENT (same day) REQUESTS MUST BE SUBMITTED BY PHONE.
eviCore healthcare | www.eviCore.com | 400 Buckwalter Place Blvd • Bluffton, SC • 29910 | 800.918.8924
1. Date of most recent office visit or contact with physician?
Date (mm/dd/yyyy): None Don't know
2. What type of stress test is being requested?
Pharmaologic Stress Test (Dobutamine) Don't know
Exercise Stress Test
3. What level of exercise is possible?
Able and willing to exercise on a treadmill
Able but unwilling to exercise on a treadmill
Impaired exercise tolerance with inability to walk at least 2 flights of stairs without stopping.
None of the above
Don't know
4. If there was a recent ECG within the last 30 to 60 days, did it show any of the following? Select all that apply.
Normal ECG
No recent ECG performed (No recent ECG will prevent expedited approval.)
ST segment depression 1 mm or greater
Non specific ST/T wave changes
LBBB/Left Bundle Branch Block
Ventricular pacemaker
None of the above
Don't know (This answer will prevent an expedited approval.)
5. What cardiac symptoms are present? Select all that apply.
No cadiac symptoms
Cardiac symptoms are present but stable
New or worsening angina or angina equivalent
New or worsening heart failure symptoms (shortness of breath)
Atypical chest pain
None of the above
Don't know
6. Is there arm pain? Yes No Don't know
7. Is there jaw pain? Yes No Don't know
8. Is the pain relieved with nitroglycerin or rest? Yes No Don't know
Page 2 of 3
Clinical Information
eviCore healthcare | www.eviCore.com | 400 Buckwalter Place Blvd • Bluffton, SC • 29910 | 800.918.8924
9. Does the pain wake the patient from sleep? Yes No Don't know
10. Is the pain worse with inspiration? Yes No Don't know
11. Does the pain occur at rest? Yes No Don't know
12. Is the pain brought on by exercise or being emotionally upset? Yes No Don't know
Yes No Don't know
14. Was there a prior PCI?
Yes, greater than 2 years ago
Yes, less than 2 years ago
There is no prior history of PCI
15. Was there a prior CABG?
Yes, greater than 5 years ago
Yes, less than 5 years ago
There is no prior history of CBG
16. When was the most recent heart stress test?
Within the last 3 months
Three months to less than 2 years ago
Two years ago or greater or no known prior stress test
Don't know
Yes No Don't know
Yes No Don't know
19. Is diabetes present? Yes No Don't know
20. Is Digoxin, Digitek, Lanoxicaps, Lanoxin a current medication? Yes No Don't know
Please attach additional pages to provide more information or comments.
Who is making this request? Ordering Physician Facility Other:
Print Name:
Title: MD RN LPN PA NP Other:
Signature: Date:
Page 3 of 3
Clinical Information
Submitter
13. Is pre-operative evaluation (“pre-op clearance”) for major vascular,
peripheral vascular or aortic surgery the main reason for the stress test?
17. Is this stress echo ordered due to a recent abnormal or equivocal
Exercise Treadmill Stress Test?
18. Is there a history of heart attack or CAD BEFORE the age of 50 in
first degree relatives (parents or siblings)?
eviCore healthcare | www.eviCore.com | 400 Buckwalter Place Blvd • Bluffton, SC • 29910 | 800.918.8924
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Stress Echo Imaging Request (eviCore)

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Completed 5 April 2022

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