Clone of Prior Authorization Services

Every Beat Counts Screening
PATIENT INFORMATION
Patient Name

First Last
Phone Number
Date of Birth
Age
Weight
Height
Gender
Are you under the care of a cardiologist (heart doctor)?
Based on the information provided, you do not meet the eligibility requirements for this screening. Please contact your cardiologist if you have any questions or would like to discuss additional options
Have you ever had heart stents or open heart surgery?
Based on the information provided, you do not meet the eligibility requirements for this screening. Please contact your cardiologist if you have any questions or would like to discuss additional options
Have you had a heart screening in the past 5 years?
Based on the information provided, you do not meet the eligibility requirements for this screening.
Do you have high cholesterol?
Do you take medication for high cholesterol?
Do you have diabetes?
Do you have high blood pressure?
Do you take blood pressure medication?
The cost of this service is $99.00. Payment is required at the time of service. We accept cash, checks, and all major credit cards.
Someone will contact you within 3 business days to give you a date and time for the testing. If you have not heard from anyone within this time frame you can call 870-541-4397
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Every Beat Counts Screening