Lab/Imaging/ECG Request

Practice NPI 1275246290

Phone: 1-800-290-5199

Fax: 786-947-6753

Email: Records@myheartspark.com

1200 Brickell Avenue Suite 1950 #1005, Miami, FL 33131
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Exam(s) Ordered
Please select from the test category you are ordering:*

LabECGElectrocardiogram, routine ECG with at least 12 leads; tracing,along with interpretation and report; CPT code 93000Electrocardiogram, routine ECG with at least 12 leads; tracingonly, without interpretation and report; CPT code 93005Electrocardiogram, routine ECG with at least 12 leads; nottracing, interpretation and report only; CPT code 93010Calcium Scan; Heart Calcium Scan; CT - Heart Coronary Calcium Score (without contrast); CPT 75571Cardiopulmonary Exercise Testing (CPET); CPT Code 94621Coronary CT Angiogram (with intravenous contrast); CPT Code 75574Ankle Brachial Index (ABI) Testing; CPT Code 93922Patient EducationNuclear Pharmacologic SPECT MPI Stress Test; CPT code 78451Nuclear Exercise SPECT MPI Stress Test; CPT code 78451Nuclear Pharmacologic PET Stress TestCardiac/Heart MRI (without stress testing); MRI - Heart With and without intravenous contrast (Without stress imaging); CPT Code 75561Cardiac/Heart MRI (with stress testing); MRI - Heart With and without intravenous contrast (With stress imaging); CPT Code 75563Exercise Stress Echocardiogram; CPT Code 93351Pharmacologic Stress Echocardiogram; CPT Code 93351Other ImagingHolter or Event MonitorOther
Select Test Categories To order:

ECGHolter or Event MonitorOther ImagingBlood TestUrine TestPatient EducationOther
ECG | Please select from the following options:*

12-Lead1-3 LeadElectrocardiogram, routine ECG with at least 12 leads; tracing, along with interpretation and report; CPT code 93000Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report; CPT code 93005Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report; CPT code 93005Other
HOLTER OR EVENT MONITOR | Please select from the following options:*

Holter Monitor (24 hours)Holter Monitor (48 hours if available, otherwise 24 hours)Holter Monitor (72 hours if available, otherwise 24 hours)Event Monitor (Ziopatch for 2 weeks if available and co-pay is acceptable to patient)Event Monitor (Ziopatch for 4 weeks if available and co-pay is acceptable to patient)Other
OTHER IMAGING | Please select from the following options:*

Transthoracic Echocardiogram (with Strain if available and EF WNL)Pharmacologic Stress Echocardiogram; CPT Code 9335Exercise Stress Echocardiogram; CPT Code 93351Hemodynamic Stress Echo with BicycleChest CT without Contrast for Calcium Scan; Calcium Scan; Heart Calcium Scan; CT - Heart Coronary Calcium Score (without contrast); CPT 75571Coronary CT Angiogram (with intravenous contrast) (and 3D FFR with Reconstruction if available); CPT Code 75574Cardiac/Heart MRI (without stress testing); MRI - Heart With and without intravenous contrast (Without stress imaging); CPT Code 75561Cardiac/Heart MRI (with stress testing); MRI - Heart With and without intravenous contrast (With stress imaging); CPT Code 75563Nuclear Pharmacologic SPECT MPI Stress Test; CPT code 78451Nuclear Exercise SPECT MPI Stress Test; CPT code 78451Nuclear Pharmacologic PET Stress TestCardiopulmonary Exercise Test (CPET); CPT Code 94621Chest x-rayAnkle Brachial Index (ABI) Testing; CPT Code 93922PYP ScanOther
BLOOD LABS | Please select from the following options:*

Comprehensive Chemistry PanelLFTsTSH ReflexLipid PanelMeasured LDLCKCKMBHigh Sensitivity Troponin SingleHgbA1CPotassiumCreatinineLipoprotein ACBCFerritinLight ChainsMonoclonal Protein StudySPEPImmunofixationNoneOther
URINE LABS | Please select from the following options:*

UrinalysisUrine CultureRandom ProteinProtein, 24 hoursLight Chains (L, K, Ratio)UPEPNoneOther
PATIENT EDUCATION | Please select from the following options:*

DietitianGenetic Counselor, and testing if applicableDiabetes EducatorHeart Failure EducationOther
Please provide the indication/reason for requesting the test(s):*
ICD-10 Codes Associated with Diagnoses or Reasons for This Test*
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THIS FORM HAS NOT BEEN *LEGITIMATELY* SIGNED BY A MY HEART SPARK P.C. CLINICIAN AND MUST NOT BE HONORED BY ANY TESTING FACILITY. IF YOU RECEIVE THIS FORM, PLEASE CONTACT US IMMEDIATELY BY CALLING 1-800-290-5199, FAXING 786-947-6753, AND/OR EMAILING RECORDS@MYHEARTSPARK.COM. THANK YOU!
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Testing/Patient Education Facility
Thank you so much for your help! We appreciate the collaboration.

Please send results to us using our secure Managing Services Organization fax line 786-947-6753, and also email the records to us at records@myheartspark.com.

You may also upload results via our detailed HIPAA compliant
Lab | Imaging | Patient Education Results Upload form.
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