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Required fields are marked with *

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Reason for Test

Cardiac Patients

Please fax the following items to 419-557-6541:
* A copy of the front and back of the patient's insurance card(s)
* Clinical notes pertaining to the reason for the ordered test are required for completion of pre-certification.
* Physician order that includes patient name, date of birth, diagnosis, test to be done, and physician signature

For questions, please call 419-557-5493 or 419-557-5494.

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