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Previous tests performed: Pertinent labs, physical therapy, home exercises, etc.
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Patient Medication/Duration
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Reason for Test

Worker's Comp?
McMurray Test Positive?

Cardiac Patients

Diabetes?
Hypertension?
Family history of heart disease?
Smoker?
If cardiac patient, has an EKG been done on patient?

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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