Follow the steps to accurately complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the 'Patient/Member' section. Enter the first name, last name, and date of birth in the specified format (mm/dd/yyyy). Provide the patient's gender, street address, apartment number (if applicable), city, state, and zip code.
3. Next, complete the 'Ordering Provider' section. Enter the ordering provider's first name, middle initial, last name, tax identification number (TIN), and national provider identifier (NPI). Fill in the physician's contact information including phone and fax numbers, address, and office contact.
4. In the 'Facility/Site' section, fill out the required details about the facility, including the group/site name, TIN, primary specialty, and site contact information.
5. Proceed to the 'Diagnosis' section. Here, specify the diagnosis, if known, and include any applicable ICD-10 codes. Also, provide the date of the last visit and any retro date of service as needed.
6. In the 'Procedure' section, check all applicable CPT codes from the provided list. Ensure that you include any additional diagnosis details if necessary.
7. Address additional questions regarding the patient's condition. Specify if unstable angina is the primary reason for the request and fill in details of the most recent office visit.
8. Indicate the main reason for the request by selecting from the options provided. Be thorough in your choices to enable expedient processing.
9. Complete the 'Clinical Information' section by selecting any relevant cardiac symptoms present or indicating if none are present.
10. Review all sections for accuracy and completeness. Once you confirm all information is correct, proceed to save changes, download, print, or share the form as necessary.

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