Fillable Cardiac - Transthoracic Echo Imaging Request (eviCore)

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Cardiac - Transthoracic Echo Imaging Request (eviCore)

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The Cardiac - Transthoracic Echo Imaging Request (eviCore) form is 3 pages long and contains:

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  • 9 check-boxes
  • 100 other fields

Country of origin: US
File type: PDF

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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:
93303 93307 93321
93304 93308 93325
93306 93320 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
Cardiac - Transthoracic 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 xfa 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
1. Date of the most recent office visit or other documented contact with physician:
Date (mm/dd/yyyy):
Less than 30 days
More than 30 days
Don't know
2. Type of most recent documented contact with physician?
Hospital
Office visit
Phone call with office staff
Phone call with physician
Email
Other (please describe):
Don't know
3. What are the reasons for requesting this Echo/TTE? Select all that apply.
Murmur
Valve disease
Hearth failure, no change in clinical status (no new symptoms)
Arrhythmias (example: atrial flutter/fibrillation, ventriculartachycardia)
Source of embolus
Known congenital heart disease
Assess results of therapy
Routine follow up study
Systemic hypertension (high blood pressure)
Scout images for stress echo
None of the above
Don't know
4. When was the most recent prior TransThoracic Echo (TTE) performed?
No prior TTE
Less than 6 months ago
Between 6 months and less than 1 year
One year or greater
Don't know
Page 2 of 3
Clinical Information
eviCore healthcare | www.eviCore.com | 400 Buckwalter Place Blvd • Bluffton, SC • 29910 | 800.918.8924
5. What heart-related conditions are new or have worsened? Select all that apply.
None
Chest pain
Leg edema (swelling)
Pulmonary hypertension
Syncope (fainting), dizziness, TIA (transient ischemic attack) or suspected stroke
None of the above
Don't know
Additional Information/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
Submitter
Clinical Information
eviCore healthcare | www.eviCore.com | 400 Buckwalter Place Blvd • Bluffton, SC • 29910 | 800.918.8924
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Cardiac - Transthoracic Echo Imaging Request (eviCore)

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Completed 5 April 2022

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