Patient Information

Patient Last Name *

Patient First Name *

Address *

City *

State *

Zip Code *

Date of Birth (MM|DD|YYYY) *

Gender *

Phone (mobile preferred) (Optional)

Medical Record Number (MRN) (Optional)

Email (Optional)

Patient Characteristics

Smoking Status (Optional)

Current

Former

Non-Smoker

ICD-10 Code *

J84.10 Pulmonary fibrosis, unspecified

J84.111 Idiopathic interstitial pneumonia, not otherwise specified

J84.112 Idiopathic pulmonary fibrosis

J84.113 Idiopathic non-specific interstitial pneumonitis

J84.116 Cryptogenic organizing pneumonia

J84.9 Interstitial pulmonary disease, unspecified

Other

For your convenience, the ICD-10 codes that are used to identify patients with single or multiple nodules are listed. Please report the code(s) that best describe the reason the test is being ordered, whether listed or not.

Percent Predicted Forced Vital Capacity % (Optional)

Date of PFTs (Optional)

Known Etiology of ILD (Optional)

Yes (If yes, fill in blank for the etiology)

Test Menu

Test Options *

Fibresolve

Diagnostic Plan

Clinician Information

You can manually enter the required information or simply enter your NPI (National Provider Identifier) to automatically search and retrieve your details.

NPI (National Provider Identifier) (Optional)

Office | Practice *

Ordering Clinician *

Address *

City *

State *

Zip Code *

Office | Practice Primary Contact (Optional)

Phone *

Fax (Optional)

Office | Practice Secondary Contact (Optional)

Phone (Optional)

Fax (Optional)

Email (Optional)

Test Result Delivery *

Fax

Mail

Secure email

By checking any of these test delivery options, you are authorizing the delivery of test results by IMVARIA Labs, in accordance with the Health Insurance Portability and Accountability Act and the rules reflected in the HITECH Act.

Data Gathering Instructions

How will the CT scan be obtained? *

The patient , radiology facility, or I will transmit the CT scan via DVD to 1515 Crescent Drive, Suite # 100, Carrollton, TX 75 00 6; OR

I will upload the CT scan directly on this website; OR

I have included the contact information including fax number for the facility with the CT scan so IMVARIA Labs can obtain the scan directly.

Estimated CT Scan Date (Optional)

Office | Practice *

Address *

City *

State *

Zip Code *

Phone *

Fax (Optional)

Email (Optional)

You are authorizing transmission of PHI to IMVARIA Labs for treatment purposes, in accordance with the Health Insurance Portability and Accountability Act and the rules reflected in the HITECH Act.

Insurance Details

Insurance Details *

Medicare

Private Insurance

Medicaid

Cash

Group / Plan ID# (Optional)

Upload additional attachments (insurance card, facesheet, medical records, etc.) (Optional)

SUBMIT FRONT AND BACK COPY OF INSURANCE CARD OR COMPLETE FACESHEET WITH INSURANCE INFO

Authorization

Please sign below *

Please provide your signature before submitting.

Your signature constitutes a certification of medical necessity and intent to consider and use the results of the test(s) ordered. All of the information on this form is true and correct. You have obtained patient consent and authorize IMVARIA to use and release the results and patient information for reimbursement purposes and as may be appropriate for additional clinical testing services.

Date (MM|DD|YYYY) *