NAVIX Diagnostix, Inc. Cardiovascular Order Form
Patient Name:
First Name
Middle Name
Last Name
Patient Date of Birth:
*
-
Month
-
Day
Year
Patient Home Phone Number
Format: (000) 000-0000.
Patient Mobile Phone Number
Format: (000) 000-0000.
Ordering Physician Name
First Name
Last Name
Ordering Physician
MD
DO
Ordering Physician Email
example@example.com
Ordering Physician Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Physician Practice Phone Number
Format: (000) 000-0000.
Exam Requested
Aorta (93978)
Arterial (Lower)
Arterial (Upper) (93930/-31)
Carotid (93880)
Dialysis Mapping Pre Surgical
Dialysis Access Duplex (93990)
Echocardiography (Transthoracic Echo) (93306)
Mesenteric Artery (93975)
Portal Venous (93975)
Renal Artery (93975)
Vein Mapping - Bypass Graft (93970/-71)
Venous DVT (Lower) (93970/-71)
Venous DVT (Upper) (93970/-71)
Venous Reflux (93970/-71)
Abdominal Aorta
Aorta Duplex
Aorta Post Operative Endovascular Repair
Other
Abdominal Aorta Indication
Abdominal Bruit
Stenosis
Aneurysm
F/U Endovascular Aorta Repair
Other
Dialysis Access Mapping (PreOperative)
Right (93986)
Left (93986)
Bilateral (93985)
Arterial Testing (Lower)
Right
Left
Bilateral
Arterial Exam Requested
Complete Lower Arterial: Ankle brachial index (ABI) (93923). If ABI is <0.96, duplex evaluation of the abdominal aorta (93978), and/or duplex evaluation lower extremity arteries (93925 bilateral/93926 unilateral) may be performed.
ABI with exercise (93923)
Resting ABI (93922)
Arterial duplex (93925/-26)
ABI (93922) with arterial duplex (93925/-26)
Aortoiliac duplex (93978)
Other
Lower Arterial Testing Indication
Claudication
S/P Stent / Bypass
Ischemia
Ulcer
Gangrene
F/U Known Stenosis
Rest Pain
Other
Arterial Testing (Upper)
Right
Left
Bilateral
Upper Arterial Testing
Upper Arterial Pressures Complete
Upper Arterial Duplex
Other
Upper Arterial Testing Indication
Claudication
S/P Stent / Bypass
Ischemia
Raynaud's
Ulcer
Gangrene
F/U Known Stenosis
Rest Pain
Other
Carotid Testing
Carotid Duplex
Subclavian Artery
Other
Carotid Testing Indication
CVA / TIA(current)
Aphasia/ Slurred Speech
Motor Deficit
Hemiparesis or Hemiplegia
Dizziness*/vertigo
Amaurosis fugax
Known Stenosis
F/U CEA
Bruit
Syncope
Motor Deficit
Known Stenosis
Other
Venous DVT (Lower)
Right
Left
Bilateral
Lower Venous Testing Indication
Superficial thrombosis
Edema
Pain in Limb
Shortness of Breath
Iliac Vein Compression
Iliac Vein Thrombosis
F/U DVT
Other
Venous DVT (Upper)
Right
Left
Bilateral
Upper Venous Testing Indication
Superficial thrombosis
Edema
Pain in Limb
Shortness of Breath
F/U DVT
Other
Venous Insufficiency
Right
Left
Bilateral
Venous Insufficiency Indication
Superficial thrombosis
Varicose Veins
Ulcer
Edema
Pain in Limb
Iliac Vein Compression
Iliac Vein Thrombosis
Other
Mesenteric Testing Indication
Abdominal Bruit
Stenosis
S/P Stent / Bypass Graft
Other
Portal Venous Testing Indication
Portal Hypertension
S/P TIPS Procedure
Other
Renal Artery Testing Indication
Hypertension
Renal Artery Stenosis
Renal Failure
Other
Vein Mapping
Right Lower
Right Upper
Left Lower
Left Upper
Bilateral Lower
Bilateral Upper
Vein Mapping Indication
Pre-operative Bypass Graft
Other
Pre-Dialysis Mapping
Bilateral Upper (93985)
Bilateral Lower (93985)
Right Upper (93986)
Left Upper (93986)
Right Lower (93986)
Left Lower (93986)
Dialysis Mapping Indication
ESRD
Stage 4 Renal Disease
Stage 5 Renal Disease
Other
Dialysis Access Evaluation
Right Upper (93990)
Left Upper (93990)
Dialysis Access Indication
Failure to mature
Low blood flows
Elevated recirculation times
Increased venous pressure
Palpable mass associated with the AVF or AVG
Loss of palpable thrill of the AVF or AVG
Arm swelling
Signs of arterial steal syndrome (e.g., hand pain, pallor, signs of digital ischemia)
Difficult access cannulation
Follow-up access revision
Other
Echocardiography
Transthoracic Echo
Echocardiography Indication
Malignant HTN
Old MI
Shortness of Breath
Benign HTN w/o Heart Failure
Chest Pain
Angina Pectoris
Murmur
Other
Other
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Physician Signature
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Medical Insurance Verification Form
Patient Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient Prefered Phone Number
Format: (000) 000-0000.
Patient Email
example@example.com
Patient Gender
Please Select
Female
Male
N/A
Patient Medical Record #
Insurance Information
Primary Insurance Co
Policy No
Group No
Primary Insurance Phone No
Format: (000) 000-0000.
Subscriber's Name
First Name
Last Name
Subscriber's Relationship to Patient
Secondary Insurance Co
Policy No
Group No
Secondary Insurance Phone No
Format: (000) 000-0000.
Subscriber's Name
First Name
Last Name
Subscriber's Relationship to Patient
Insurer Information
Name of Insurer
Name of Insurance Rep
First Name
Last Name
Rep Phone Number
Format: (000) 000-0000.
Referral Contact Name
First Name
Last Name
Referral Phone Number
Format: (000) 000-0000.
Notes
Appointment
Is Submitted
Facility Address
Consent for Treatment and Financial Responsibility Agreement
HIPAA Acknowledgement
Primary Insurance Front
Primary Insurance Back
Secondary Insurance Front
Secondary Insurance Back
Patient License Front
Patient License Back
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