PATIENT ENROLLMENT FORM
Please scroll down to complete the form below, which includes the following sections:
Duration of Monitoring
Here are some common diagnosis codes for cardiac monitoring: R00.2 (Palpitations), R55 (Syncope and collapse), I48.0 (Paroxysmal atrial fibrillation), R00.1 (Bradycardia), R42 (Dizziness and giddiness), R00.0 (Tachycardia), I47.1 (Supraventricular tachycardia), I49.9 (Cardiac arrhythmia).
I authorize the above ordering physician to release any necessary medical or demographic information concerning above named patient to Artella Solutions Inc. I acknowledge responsibility for the assigned Artella Solutions monitor. Upon completion of service, I will return the monitor in good working order to Artella Solutions Inc. Failure to do so will result in my being charged $1850.00 for replacement of the monitor. If not returned within 36 hours I will be charged $150.00 per day until returned.