Patient Information

LOCATIONS:

REFERRAL FORM
Please print this form, fill it out and take it with you to the doctor's office.

	Patient Name ____________________________________________________ Diagnosis _______________________________________________________ Appointment Date ________________________________________________
	Referred For: Consultation Echo w/Doppler/Color Flow Stress Test Stress Echo Pharmacologic Exercise Event Recorder Holter Monitor Carotid Ultrasound Venous Ultrasound Lower Arterial Evaluation TEE Catheterization Coronary Intervention Other ________________	Nuclear Medicine Thallium Exercise Dobut Adeno Dual-Isotope Exercise Dobut Adeno MUGA
	Referring Physician: __________________________________________ Telephone: _______________________ Fax: _______________ Circle (if applicable): Stat reading Call with results Fax Results

Accepted Carriers

Anthem AARP Acordia Administrative Services AETNA Affordable Medical Network AFLAC Alliance (PPO) Alliance (GEHA) American Pioneer Insurance BCBS Benefit Concepts Benefit Planners Benefit Plan Admin Blue Choice Board of Pensions Capp Care Carefirst Admin. Carefirst BCBS CIGNA C.N.A. Colonial Life Combined Govt. Health Plan Continental Live	Connecticut General Coresource Corporate Benefits EDS Health Benefit Plan Employee Benefit Concepts First Health Fortis General American Great West Group Benefit Services Guardian John Alden John Hancock Liberty Mutual Mail Handlers MAMSI Life and Health MDIPA Mediplus Monumental Mutual of Omaha	NACS NALC Nationwide Insurance NCAS NCPPO One Health Plan Optimum Choice Inc. PHCS Pioneer Life Provident Railroad Medicare Southern Health Services Qual Choice State Farm Insurance Medicare Tricare Trustmark Unicare United American United Healthcare USAA Life VA Medicaid Medallion VA Medicaid

Please feel free to call our billing department as we are always adding new insurance carriers.
703-331-0300
8:30 am - 4:30 pm M - F

PATIENT INSTRUCTIONS

Echocardiogram: Women are asked to wear a two-piece outfit.

Stress Test or Stress Echo:

Do not eat, drink, or smoke four hours prior to the time of your appointment. (Please eat regular meals and drink plenty of fluids the day before the stress test. )
If you are a diabetic, please make sure you eat two hours prior to your stress test and bring a snack or juice for after you have completed your test.
Bring a list of all your medications. Be sure to note the dose and how often you take each medication.
Bring or wear comfortable shorts or pants and tennis or other rubber soled shoes that will be comfortable to walk in.
Do not use any powder or lotion on your chest area the day of your stress test.
You may wish to bring a towel in the event that you exercise long enough to work up a sweat.

Nuclear Stress Testing:

Do not eat or drink after midnight prior to study except for water with prescribed medications.
Remain on medications unless otherwise indicated by your physician.
Diabetic patients should not take their meds but bring it with them.
Wear comfortable clothing and shoes to exercise in.
No caffeine 24 hours prior to study. (For example: no chocolate, coffee, tea, soda, etc. including decaf/caffeine free drinks).