Fillable Cardiac Nuclear Imaging Request (MPI) (eviCore)

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Cardiac Nuclear Imaging Request (MPI) (eviCore)

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The Cardiac Nuclear Imaging Request (MPI) (eviCore) form is 4 pages long and contains:

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  • 164 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:
78451
78454
78469 78481 78496
78452
78466
78472 78483 78499
78453
78468
78473 78494 Other:
Diagnosis, if known or rule out:
ICD-10 Codes:
Retro Date of Service:
Page 1 of 4
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 Nuclear Imaging Request (MPI)
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 most recent office visit or other documented contact with physician:
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 No Don't Know
4. What symptoms are present?
No symptoms (asymptomatic)
Syncope
Symptoms are present but stable
Documented ventricular tachycardia (VT)
New or worsening angina or angina equivalent
None of the above
New or worsening atypical chest pain
Don’t know
New or worsening heart failure (CHF)
5. Is there arm pain? Yes No Don't Know
6. Is there jaw pain? Yes No Don't Know
7. Is the pain relieved with nitroglycerin or rest? Yes No Don't Know
8. Does the pain wake the patient from sleep? Yes No Don't Know
9. Is the pain worse with inspiration?
Yes No Don't Know
10. Does the pain occur at rest? Yes No Don't Know
11. Is the pain brought on by exercise or when emotionally upset? Yes No Don't Know
12. Was there a prior PCI?
Yes, greater than 2 years ago No, there is no prior history of PCI
Yes, less than 2 years ago
13. Was there a prior CABG?
Yes, greater than 5 years ago No, there is no prior history of CABG
Yes, less than 5 years ago
14. If exercise on a treadmill is not possible, please explain why:
N/A
15. Has an ECG been done in the past 60 days? Yes No Don't Know
Page 2 of 4
eviCore healthcare | www.eviCore.com | 400 Buckwalter Place Blvd • Bluffton, SC • 29910 | 800.918.8924
16. What were the results of an ECG done within the last 60 days?
An ECG was not done within the last 60 days Hemiblock
Normal ECG Ventricular pacemaker
Nonspecific ST/T wave changes LVH with early repolarization
Complete LBBB (Left Bundle Branch Block) WPW/pre-excitation
Complete RBBB (Right Bundle Branch Block) Digoxin effect
Incomplete RBBB (Right Bundle Branch Block) None of the above
T wave inversion in the inferior and /or lateral leads
Don’t know
17. Is there documentation of Ventricular Tachycardia (VT)? Yes No Don't Know
Yes No Don't Know
19. What is the resting heart rate?
Less than 50 beats per minute Greater than 60 beats per minute
50 to 60 beats per minute Don't know
20. What is the body weight in pounds?
Don't know
21. What is the height in inches?
Don't know
22. Select all cardiac risk factors that this individual has:
Obesity
Cerebrovascular disease (TIA, stroke)
None of the above
Don't know
Diabetes
High blood pressure
Hyperlipidemia (high cholesterol, etc…)
Smoker
Obstructive Sleep Apnea
Yes, before age 50 No
Yes, after age 50 Don't know
Yes, unknown age
Yes No Don't Know
Yes No Don't Know
26. Is there a personal history of cancer? Yes No Don't Know
Page 3 of 4
25. Does this individual have a history of a false positive Exercise
Treadmill Stress Test?
18. Is there new congestive heart failure (CHF) or new Left Ventricular
(LV) dysfunction?
23. Is there a history of heart attack or coronary artery disease (CAD) in a first degree relative such as a parent or
sibling?
24. Is this study being requested because there was a recent abnormal
or equivocal Exercise Treadmill Stress Test (ETT)?
eviCore healthcare | www.eviCore.com | 400 Buckwalter Place Blvd • Bluffton, SC • 29910 | 800.918.8924
1 to less than 2 years ago
2 to 5 years ago
More than 5 years ago
No imaging stress test has ever been done
Less than six months ago
Six months to one year ago
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 4 of 4
Clinical Information
Submitter
27. When was the most recent imaging stress test performed (example: nuclear stress test, stress echo, or stress
MRI)?
eviCore healthcare | www.eviCore.com | 400 Buckwalter Place Blvd • Bluffton, SC • 29910 | 800.918.8924
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Cardiac Nuclear Imaging Request (MPI) (eviCore)

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Completed 5 April 2022

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