Cardiac Rhythm Implantable Device
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:
Physician Phone: Physician Fax:
Office Contact: Ext:
Contact Email:
Group/Site Name:
Primary Specialty:
33207
33221
33229
33262
33263 33264 Other:
Diagnosis, if known or rule out:
ICD-10 Codes:
Date of last visit: Retro Date of Service:
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applicable CPT
Codes:
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Secondary prevention in a survivor of cardiac arrest due to VT or VF
without CRT, requiring an ICD
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