CLMRAD Echo Questionnaire

Patient Name *

Date of Birth *

The Australian Government has made changes to Medicare/DVA funded cardiac imaging services to supporthigh-value care and ensure patients have access to the most appropriate tests for their individual symptomsand conditions.

To help us understand your circumstances, please answer the following questions:

Have you been to a Cardiologist, Hospital, or other imaging provider in the last 2 years for heart related issues? *

YesNo

Have you had an Echocardiogram in the last 2 years? *

YesNo

When and where was that done? *

Is your referral from a: *

GPSpecialist

Are you taking any cardio-toxic medications? (eg Clozapine or similar) *

YesNo

Are you currently undergoing, or recently completed chemotherapy in the last six months? *

YesNo

Is your doctor querying Pericarditis? *

YesNo

By signing below, you (the patient) confirm that:

The answers given above are true and accurate to the best of your knowledge *

MEDICARE PATIENTS: I agree to pay $219.50 and acknowledge I may receive up to a 100% rebate if my claim is accepted by Medicare based on their criteria.
*

DVA PATIENTS: I acknowledge that if DVA reject my claim, I am responsible for theoutstanding amount of $219.90. *

Patient Signature

Draw signature|Type signatureClear

Today's date

Please wait, files are uploading..

Save and Complete Later

Your response has been saved, but not yet submitted.

To come back and continue later, please use this URL:

Copy URL

Technician’s Declaration:

I have reviewed and confirmed all information with the patient.

Name: _____________________________ Signature:_____________________________ Date: _________________

Office Use

Patient quoted fee $____________Checked other imaging providersScanned previous reports into patient visit

Staff Initials: _________________________ Date:__________________________