MD Order

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Patient Information
Todays Date*
Requested Enrollment date(s):*
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
DOB*
SS#*
Gender*
- Male
- Female
Day Phone*
Evening Phone*
Best time to reach patient*
Billing Information
Primary Insurance
Primary Insurance*
Phone*
Address*
Policyholder Name*
First Last
Policy #*
Group #*
Policyholder DOB*
Referral/authorization #*
Secondary Insurance
Secondary Insurance
Phone
Address
Policyholder Name
First Last
Policy #
Group #
Policyholder DOB
Referral/authorization #
Physician Order and Statement of Medical Necessity
Patient Has Chronic AF*
- Yes
- No
Turn Off AF Trigger*
- Yes
- No
Turn Off AF Trigger After First Physician Notification*
- Yes
- No
Reminder: It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.
Please Choose The Correct Diagnosis*
- Atrial Fibrillation I48.91
- Tachycardia Unspecified R00.0
- Bradycardia Unspecified R00.1
- Congestive Heart Failure I50.9
- Supraventricular Tachycardia I47.1
- Ventricular Tachycardia I47.2
- Syncope and Collapse R55
- Dizziness; Giddiness; Light-headedness; Vertigo NOS R42
- Hypertension I10
- Palpitations R00.2
- Unspecified abnormalities of breathing R06.9
- Dyspnea R06.00
- Chest Pain, unspecified R07.9
- Snoring R06.83
- Long-term (Current) Use of Anticoagulants* Z79.01
- Other
Other Diagnosis*
Physician’s Signature*
# of Days:*
Physician Information
Name*
First Last
NPI #*
Medical Group*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Fax
Email*
Email
This field is for validation purposes and should be left unchanged.

Contact Information

8019 Ridgeway Ave Skokie, IL

administration@heartmedllc.com847-443-1170

SHAPARAK MARKETING

MD Order

Patient Information

Billing Information

Primary Insurance

Secondary Insurance

Physician Order and Statement of Medical Necessity

Physician Information