EKG REQUEST FORM

Specialty Portable X-Ray, Inc. & EKG

Paul J. Fowler

5000 Long Beach Road - Island Park, NY 11558
1-800-554-4229 * 516-432-3800
Fax: 516-897-3915

Cardiologist: Jeffrey Schaffer, M.D. F.A.C.C

For Office User Only
Facility: 

_________________________
Technician:

_________________________
Time of Exam:

_________________________
# of Patients Seen:

_________________________
Date of Service:

_________________________
Copy Left at Facility?

Yes: ______    No: ______       

 

ALL INFORMATION IN THIS SECTION MUST BE COMPLETED

PLEASE PRINT
 
Patient's Name:
 __________________________________________________________________
(Last)                                                               (First)                                                               
Date of Birth: _____________________________ Male: ____________ Female: ____________
Medicare: _________________________ Suffix: __________ Medicaid: ________________
Other Insurance: _____________________________ Insurance #: __________________________
Room No.: ___________  Facility where Patient Resides: _____________________________
Ordering Physician:

__________________________  Address: _______________________________

Guarantor's Name and Address: ___________________________________________________________

____________________________________________________________________________________
Physician's Signature: __________________________________________________________________
  Medicaid I.D. #:_________________              Medicare I.D. #:_________________
PATIENT OR AUTHORIZED PERSON'S SIGNATURE:
I authorize the release of any medical information
necessary to process this claim and request pay-
ment of benefits either to myself or the party who
accepts assignment.

____________________________ Date: ________ Time: ________
Cardiac History:

_______________________________________________________________________
Cardiac Medications, If Any:

______________________________________________________________

____________________________________________________________________________________
Does Patient Have a Pacemaker?

Yes: _____  No: _____ Unknown: _____
 

PLEASE CHECK ONE

____ 12 Lead EKG With Rhythm Strip

____ Pacemaker Test

____ Holter Monitor


NOTICE TO OFFICIALS: A Portable EKG is being ordered since this patient would find it physically and/or psychologically taxing, because of
advanced age and/or physical limitations to receive EKG outside this home.
Assignment Accepted:   ____ Yes   ____ No