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Philips Remote Cardiac Services 7 Waterside Crossing Windsor, CT 06095 Physician Order for ICD Monitoring r Remote Monitoring r Telephone Monitoring Account Information: Name: Contact Name: Address: Phone: City: State: Zip: Email: Ordering Physician Information: Name: Business Phone: Account #: NPI#: Business Fax: Patient Information: Clinic’s Patient ID#: Date of Birth: Gender: r Male r Female Name: SSN: Street: Next of Kin: City: State: Zip: Phone: Cell: Phone: Cell: ICD Information: Complete below or provide a copy of patient implant record Manufacturer Model Number Serial Number Implant Date Wireless? Pulse Generator (ICD) r Yes r No Atrial Lead Ventricular Lead Left Ventricular Lead Diagnosis Code: (reason for implant): Insurance: Complete below or provide a copy of both sides of patient insurance card. Medicare Part B Number (include all letters): Managed Care: r HMO r PPO PCP Name: Phone: Primary Insurance Secondary Insurance Insurance Company Name: Address: City/ST/Zip: Phone: Insured’s Name: Insured’s Date of Birth: Patient Ins. ID Number: Group ID Number:
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This note was uploaded on 12/26/2009 for the course PHYS 341 taught by Professor Mavromatis during the Spring '09 term at American University of Beirut.

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DownloadServlet - Philips Remote Cardiac Services 7...

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