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
Today's Date*

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Patient Information
MHS MRN
Patient Name:*

First NameLast Name
Patient Sex*
Patient Date of Birth*

MonthDayYear
Height
Weight
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Patient Phone*
YesNoN/A
YesNo
NoneLatexContrastIodineOther
YesNo
Billing
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Insurance/Plan*
Member # / ID*
Authorization #
Authorization Valid From:

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To:

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Ordering Provider
Full Name of Ordering/Referring Clinician*

PrefixFirst NameLast Name
NPI # (if First Time Ordering)
Clinician Phone*
Name of Clinic*
Clinic Contact*
Clinic Fax *
Exam(s) Ordered
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
ECGHolter or Event MonitorOther ImagingBlood TestUrine TestPatient EducationOther
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 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
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
Comprehensive Chemistry PanelLFTsTSH ReflexLipid PanelMeasured LDLCKCKMBHigh Sensitivity Troponin SingleHgbA1CPotassiumCreatinineLipoprotein ACBCFerritinLight ChainsMonoclonal Protein StudySPEPImmunofixationNoneOther
UrinalysisUrine CultureRandom ProteinProtein, 24 hoursLight Chains (L, K, Ratio)UPEPNoneOther
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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MD2 Code
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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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