PATIENT INFORMATION	

NAME: 	<PtFullName>	

DATE OF BIRTH: <PtDoB>	
MEDICARE NO.: <PtMCNo>	

ADDRESS: <PtStreet>	

SUBURB: <PtCity>	
POST CODE: <PtPostcode>	

EXAMINATION REQUESTED (Medicare Eligible items are bulk billed) <EXAMINATION REQUESTED (Medicare Eligible items are bulk billed)>	

<Echocardiogram> Echocardiogram	
<Echocardiogram : 55126 Repeat Echocardiogram> 55126 Repeat Echocardiogram	
<Echocardiogram : 55133 Pericardial effusion, pericarditis or cardiotoxic> 55133 Pericardial effusion, pericarditis or cardiotoxic	
<Echocardiogram : 55127 Valvular Dysfunction> 55127 Valvular Dysfunction	

<Echocardiogram : 55129 Heart Failure or Structural Heart Disease> 55129 Heart Failure or Structural Heart Disease	
<Echocardiogram : 55132 (ACHD Specialist) Congenital Heart Disease> 55132 (ACHD Specialist) Congenital Heart Disease	

<Exercise Stress Echocardiogram> Exercise Stress Echocardiogram 
(For Medicare eligibility  Part B must be completed)	

<Lung V/Q scans> Lung V/Q scans	
<HIDA Scan> HIDA Scan	
<Parathyroid Scan> Parathyroid Scan	
<Thyroid Scan> Thyroid Scan	

<Bone Scan> Bone Scan	
<Amyloid Bone Scan> Amyloid Bone Scan	
<Meckel’s Scan> Meckel’s Scan	
<Gastric Emptying Study> Gastric Emptying Study	

<Myocardial Perfusion Scan (For Medicare eligibility Part A and Part B must be completed, restricted to once in a 2 year period.> Myocardial Perfusion Scan (For Medicare eligibility Part A and Part B must be completed, restricted to once in a 2 year period. 	

CLINICAL INDICATIONS
<Clinical Indications:>

	

PART A. MEDICARE ELIGIBILITY REQUIREMENTS FOR MYOCARDIAL PERFUSION SCAN. (PTO FOR EXERCISE STRESS ECHOCARDIOGRAM MEDICARE REQUIREMENTS)	

The patient has symptoms of cardiac ischaemia where at least one of the following applies: <The patient has symptoms of cardiac ischaemia where at least one of the following applies:>
<the patient has body habitus or other physical condition/s (including heart rhythm disturbance) to the extent where a stress echocardiography would not provide adequate information; or> the patient has body habitus or other physical condition/s (including heart rhythm disturbance) to the extent where a stress echocardiography would not provide adequate information; or	

<the patient is unable to exercise to the extent where a stress echocardiography would not provide adequate information; or> the patient is unable to exercise to the extent where a stress echocardiography would not provide adequate information; or	

<the patient has had a failed stress echocardiography provided under a service to which item 55141, 55143, 55145 or 55146 applies; or> the patient has had a failed stress echocardiography provided under a service to which item 55141, 55143, 55145 or 55146 applies; or	

<the patient has had an assessment of undue exertional dyspnoea of uncertain aetiology (specialist or consultant physicians only)> the patient has had an assessment of undue exertional dyspnoea of uncertain aetiology (specialist or consultant physicians only)	

REFERRING DOCTORS DETAILS	

Referring Clinician:	
<DrName>	
Provider No.:	
<DrProviderNo>	

Address:	
<DrStreet> <DrCity> <DrPostcode> <DrState>	

Signature:	
	
Date:	
<TodaysDate>	

STRESS TEST CLINICAL INDICATIONS FOR MEDICAL ELIGIBLITY (PART B.) <CLINICAL INDICATIONS FOR MEDICAL ELIGIBLITY (PART B.)>
The request for service must identify at least one of the following (Please tick) <The request for service must identify at least one of the following (Please tick)>	

<if the patient displays one or more of the following symptoms of typical or atypical angina:> (a) if the patient displays one or more of the following symptoms of typical or atypical angina:
i.	constricting discomfort in the front of the chest, neck, shoulders, jaw, arms; or <constricting discomfort in the front of the chest, neck, shoulders, jaw, arms; or>
ii.	the patient’s symptoms are precipitated by physical exertion; or <the patient’s symptoms are precipitated by physical exertion; or>
iii.	the patient’s symptoms are relieved by rest or glyceryl trinitrate within 5 minutes or less; or <the patient’s symptoms are relieved by rest or glyceryl trinitrate within 5 minutes or less; or>
<if the patient has known coronary artery disease, and displays one or more symptoms that are suggestive of ischaemia:> (b) if the patient has known coronary artery disease, and displays one or more symptoms that are suggestive of ischaemia: 
i.	which are not adequately controlled with medical therapy; or <which are not adequately controlled with medical therapy; or>
ii.	have evolved since the last functional study; or <have evolved since the last functional study; or>
<if the patient qualifies for one or more of the following indications:> (c) if the patient qualifies for one or more of the following indications: 
i.	assessment of myocardial ischaemia with exercise is required if a patient with congenital heart lesions has undergone surgery and  reversal of ischemia is considered possible; or <assessment of myocardial ischaemia with exercise is required if a patient with congenital heart lesions has undergone surgery and  reversal of ischemia is considered possible; or>
ii.	assessment indicates that resting 12 lead electrocardiogram changes are consistent with coronary artery disease or ischaemia, in a patient that is without known coronary artery disease; or <assessment indicates that resting 12 lead electrocardiogram changes are consistent with coronary artery disease or ischaemia, in a patient that is without known coronary artery disease; or>
iii.	coronary artery disease related lesions, of uncertain functional significance, which have previously been identified on computed tomography coronary angiography or invasive coronary angiography; or <coronary artery disease related lesions, of uncertain functional significance, which have previously been identified on computed tomography coronary angiography or invasive coronary angiography; or>
iv.	assessment by a specialist or consultant physician indicates that the patient has potential non-coronary artery disease, where a stress echocardiography study is likely to assist the diagnosis; or <assessment by a specialist or consultant physician indicates that the patient has potential non-coronary artery disease, where a stress echocardiography study is likely to assist the diagnosis; or>
v.	assessment indicates that the patient has undue exertional dyspnoea of uncertain aetiology; or <assessment indicates that the patient has undue exertional dyspnoea of uncertain aetiology; or>
vi.	a pre-operative assessment of a patient with functional capacity of less than 4 metabolic equivalents confirming that surgery is intermediate to high risk, and the patient has at least one of following conditions: <a pre-operative assessment of a patient with functional capacity of less than 4 metabolic equivalents confirming that surgery is intermediate to high risk, and the patient has at least one of following conditions:>
a.	ischaemic heart disease or previous myocardial infarction; or <ischaemic heart disease or previous myocardial infarction; or>
b.	heart failure; or <heart failure; or>
c.	stroke or transient ischaemic attack; or <stroke or transient ischaemic attack; or>
d.	renal dysfunction (serum creatinine > 170umol/L or 2 mg/dL or a creatinine clearance of less than 60 mL/min); or <renal dysfunction (serum creatinine > 170umol/L or 2 mg/dL or a creatinine clearance of less than 60 mL/min); or>
e.	diabetes mellitus requiring insulin therapy: or <diabetes mellitus requiring insulin therapy: or>
vii.	assessment before cardiac surgery or catheter-based interventions is required to: <assessment before cardiac surgery or catheter-based interventions is required to:>
f.	increase the cardiac output to assess the severity of aortic stenosis; or <increase the cardiac output to assess the severity of aortic stenosis; or>
g.	determine if valve regurgitation worsens with exercise and/or correlates with functional capacity; or <determine if valve regurgitation worsens with exercise and/or correlates with functional capacity; or>
h.	correlate functional capacity with the ischaemic threshold; or <correlate functional capacity with the ischaemic threshold; or>
viii.	for patients where silent myocardial ischaemia is suspected, or due to the patient’s cognitive capacity or expressive language impairment, it is not possible to accurately assess symptom frequency based on medical history. <for patients where silent myocardial ischaemia is suspected, or due to the patient’s cognitive capacity or expressive language impairment, it is not possible to accurately assess symptom frequency based on medical history.>

	

CLINIC LOCATION
		PATIENT PREPARATION
Myocardial Perfusion scan.
No caffeine (tea, coffee, coke, chocolate, milo) for 24hrs before test.
Fast for 4 hours before the test.
Gastric Empty Study
Fast from midnight on the day of the test. Some medications can interfere with the study and may need to be ceased. Please contact QNI 
HIDA (Biliary Scan)
Fast for 4 hours before the scan
Meckel’s Scan
Fast for 4 hours before the scan
Thyroid Scan
Some medications can interfere with the study and may need to be ceased. Please contact QNI for instructions