Patient:

Patient Phone

Date

DOB

Insurance Group

Insurance Member ID

Referring Physician

Office Phone

Fax

Referred for

Cardiac Rehabilitation External Counterpulsation (ECP) Therapy

Myocardial Infarction (STEMI or NSTEMI) within the past 12 months, Date(s)
Coronary Artery Bypass Graft Surgery, no time limit, Date(s)
Percutaneous Transluminal Coronary Angioplasty (PTCA) or coronary stenting, no time limit, Date(s)
Heart valve repair or replacement, no time limit, Date(s)
Heart or heart-lung transplant, no time limit, Date(s)
Current Stable Angina Pectoris
Heart Failure (Class II, III, or IV) with Ejection Fraction < 35%

Notes

The staff at Sterling Heart Care will contact the referred patient regarding scheduling, insurance authorization, and medical record requests. Referring physicians and their teams will be kept up to date regarding their patient’s registration, scheduling, program adherence, and results. Please call our office at 716-529-3131 with any questions, comments, or concerns. We appreciate the opportunity to participate in your patient’s care.

Referral Form