Patient
Information

 Appointment
Information
Patient
Registration Forms
Accepted Insurance
Prescription Refills
Procedure
Preparation
Education Links
Ask a Question
home 		 










We can help you get answers

If you didn’t find the information you were looking for in our website, please feel free to send us your question. We’ll have an answer for you shortly.
Referral Information:
Referral Doctor:
Phone Number:
Email Address:
Sent By:
Date:
Address:

City, State, Zip:
Fax Number:
UPIN Number:
Medicaid Number:
   
Patient Information:
Patient Name:
Address:
City, State, Zip:
Home Phone:
Work Phone:
SSN:
Date of Birth:
Primary Insurance:
Diagnosis:
Please check:
Patient over 300 lbs
EKG, labs and Insurance card faxed
Patient instructed to bring all medications and supplements in original containers
If Anthem or Aetna precertify stress test
   
Service or Procedure Ordered:
Cardiovascular consultation
Preoperative cardiac assessment
Electrophysiology (cardiac arrythmia & syncopal evaluation)
   
Lab Tests:
Lipid Profile: yes | no
ALT/AST: yes | no
COCVC to manage? yes | no
   
Stress Tests:
Nuclear Stress Test: yes | no
Stress Echo: yes | no
Excercise Tolerance Stress Test: yes | no
   
Ultrasound Studies: (stat patients can be ordered)
Echocardiography (2D color doppler): yes | no
Carotid Duplex Study (Extracranial): yes | no
   
Venous Color Duplex Studies: (stat patients can be ordered)
Upper Extremity: R | L | B
Lower Extremity: R | L | B
   
Arterial Doppler Studies:
Upper Extremity: yes | no
Lower Extremity: yes | no
   
Other Tests:
Bioimpedance: yes | no
24hr Ambulatory BP Monitor: yes | no
   
Electrophysiology Studies:
Holter Monitor: yes | no
Event Recording: yes | no
Micro volt T-wave Alternan: yes | no
   
Location:
Additional Comments:
   
 
 


  “I’m only 48, but my doctor said I was at risk for a heart attack and sent me to COCVC for tests. The doctors and staff took the time to really explain things to me. I felt better even before my treatment began.”

— Jim, COCVC Patient		  

Columbus
5131 Beacon Hill Road
Suite 120
[map this location]

Dublin
6670 Perimeter Drive
Suite 140
[map this location]

Marysville
171 Morey Drive
Suite C
[map this location]

Nelsonville
1950 Mt. Saint Mary Dr.
[map this location]

Athens
 

© 2008 Central Ohio Cardiovascular Physicians Privacy Policy & Legal Terms