REFERRAL FORM

Dr Jilani Latona		Dr Reza Reyaldeen		
				
MBChB, FRACP Cardiologist		MBBS, FRACP Cardiologist		
404181GH		6335279A		

Patient’s Name:

Address:

Date of Birth:	 Phone:

Medicare Number:

INVESTIGATIONS REQUESTED:

GP & Specialist Referral

Cardiac consultation 
Echo - Initial comprehensive (55126)

Rebatable once every 2 years

Serial echo pericardial disease/ cardiotoxicity (55133)

No claim limit

Exercise stress echocardiogram (55141)

Rebatable once every 2 years

Holter monitoring (11716)

Rebatable once every 4 weeks

Specialist Referral Only

Serial echo (55127)

Valvular disease

No claim limit

Serial echo (55129)

Structural heart disease

No claim limit

Serial echo for rare cases (55134)

No claim limit

Repeat exercise stress echo (55143)

Rebatable once every 12 months

7-day event monitoring (11723)

Rebatable once every 3 months

30 day event monitor

24-hour blood pressure monitor

12-lead ECG (reported) (11704)

No claim limit

The Australian Government has made changes to Medicare-funded cardiac imaging services, therefore rebates are subject to clinical details that meet Medicare eligibility requirements.
For more information please refer to

www.mbsonline.gov.au

PLEASE TURN OVER for testing

duration and consultation fees.

Clinical Details:

Referring Doctor:	

Practice Name:

Provider No.:

Referral Date:	Signature:

Please Email this referral back to us on reception@brisbanecardiac.com.au

We offer bulk billed tests, consultation fees apply.

Phone 07 3188 1515 | Fax 07 3112 6166 reception@brisbanecardiac.com.au

www.brisbanecardiac.com.au