The HeartScreen.
Referral
BestPractice template	PH: 07 3067 5580
FAX: 07 3067 5581
admin@theheartscreen.com.au	

PATIENT DETAILS	REFERRER DETAILS	
Name: <PtFullName>
DOB: <PtDoB>
Address: <PtStreet> <PtCity> <PtState> <PtPostcode>
Phone: <PtPhoneH>   Mobile: <PtPhoneMob>
Medicare No: <PtMCNo> <PtMCLine>
Reference No:	Referral Date: <TodaysDate>
Doctor: <DrName>
Provider Number: <DrProviderNo>
Practice Name: <Practice>
Address: <UsrAddress>
Phone No: <UsrPhone>	

REQUEST DETAILS	
ECHO HISTORY / ELIGIBILITY CHECK	
Has the patient had any Echo done in the past 24 months?
☐ Yes ☐ No
If Yes, you will have to pay an out-of-pocket fee.
Whether a prior echo or related item was done in the last 24 months, and if known, when: ________________________________
• Any known conflicting cardiac imaging already booked or recently performed: ________________________________	
TRANSTHORASIC ECHOCARDIOGRAM
MBS 55126 / 55127 / 55128 / 55129 / 55132 / 55133 / 55134
Medicare eligible if clinical criteria met.
Primary Clinical Indications (tick at least one)
☐ Symptoms or signs of heart failure
☐ Dyspnoea (rest or exertion)
☐ Fatigue
☐ Peripheral oedema / fluid retention
☐ Suspected ventricular dysfunction or hypertrophy
☐ Long standing hypertension with suspected LVH
☐ Abnormal ECG suggestive of LVH
☐ New cardiac murmur and strong family history
☐ Known valvular disease - monitoring
☐ Pulmonary hypertension
☐ Pericardial disease
☐ Aortic disease
☐ Congenital heart disease
☐ Suspected cardiomyopathy
☐ Cardiac source of embolus
☐ Prior to cardiotoxic therapy
☐ Diabetes with dyspnoea
☐ Obesity with exertional SOB
☐ Other (specify): ____________________
☐ STRESS ECHOCARDIOGRAM
MBS 55141 - Bulk bill if criteria met
☐ Suspected coronary artery disease
☐ Exertional chest pain
☐ Functional capacity limitation
☐ Ischaemia assessment	☐ 24-HOUR HOLTER MONITORING
MBS 11716 - Bulk bill if criteria met
☐ Recurrent palpitations
☐ Syncope / presyncope
☐ Suspected arrhythmia
☐ AF burden assessment
☐ Medication effect monitoring
Frequency requirement: Symptoms occurring at least once per week.	
☐ 7-DAY HOLTER MONITORING
MBS 11723 - Private unless meeting extended monitoring criteria
☐ Infrequent palpitations (< weekly)
☐ Intermittent arrhythmia suspicion
☐ AF monitoring	☐ 24 HOUR AMBULATORY BP MONITORING
MBS 11607 - Medicare eligible if criteria met
☐ Suspected white coat hypertension
☐ Suspected masked hypertension
☐ Treating hypertension requiring confirmation	

☐ 12-LEAD ECG
MBS 11707 - Trace only (Bulk bill eligible)
☐ Chest pain
☐ Palpitations
☐ Syncope
☐ Hypertension review
☐ Arrhythmia suspicion
☐ Cardiovascular risk assessment
☐ OTHER INDICATION - NO MBS REBATE
Clinical notes:	<Clinical Notes?>	
On behalf of your patient, please send a copy of this referral to admin@theheartscreen.com.au