AUTONOMIC TESTING INFORMATION (rev. 11/20/00)

Please bring this sheet to your appointment

1. What is autonomic testing?

The autonomic nervous system is that part of the brain, spinal cord and nerves that controls involuntary functions. Blood pressure, heart rate, sweating, the bladder, the bowel and sexual function are some examples. Autonomic testing assesses this system. We check heart rate and blood pressure while you breathe deeply, bear down or stand up. Capsules attached to the surface of the skin check sweating while your body is warmed up. When the problem is limb pain, blood pressure and heart rate tests may not be done. Instead we check blood flow in your skin, and muscles, skin temperature and the amount of swelling. The whole thing takes about 3 hours and is non-invasive.

2. How do I schedule an appointment?

By law, we cannot test anyone without a written physician referral. Please have this referral ready when you call and bring it with you to your appointment (or we will not be able to test you). If the physician has already filled out part 7, this is the referral.

The scheduling number is (216) 844-3496. The autonomic laboratory is located in the Bolwell Health Center of University Hospitals of Cleveland on the second floor, room 2700.

Because autonomic testing requires so much preparation on both your part and the part on the laboratory we ask you to please give us a 48 hour notice if you cannot keep your appointment. This will allow us to schedule someone else in your place with enough time to stop their medications.

3. Where do I get my results?

We will send your results to your referring physician in 7-10 days. A copy of the actual report may be obtained from your physician or from Medical Records (216) 844-3519.

4. How do I insure accurate testing?

Many medications and other substances affect the function of the autonomic nervous system we are measuring. We therefore ask the following:

a. No nicotine (cigarettes) or caffeine (tea, hot chocolate, chocolate, coffee, and caffeinated soft drink) 3 hours before your study.

b. No alcoholic drinks 14 hours before your study.

c. No constrictive clothing such as Jobst stockings, corsets on the morning of the study.

d. Please eat and drink normally for 24 hours prior to testing except for caffeine.

e. Your skin should be clean without lotions, oils or creams.

f. If you have a PACEMAKER, please call our office for special arrangements.

g. No over-the-counter or prescribed cold, allergy, cough, anti-inflammatory or antihistamine medication. Anti-depressant and blood pressure medications, if permitted by your primary physician should be stopped 48-72 hours prior to the study. Please work with your primary care physician regarding these medications. If medications are unsafe to stop, we will still test you and take this into account when interpreting the results.

5. How do I know if my insurance company will pay for autonomic testing?

All patients must be pre-certified by their insurance company prior to testing. You may obtain pre-certification directly from your insurance company at the phone number listed on the back of your insurance card. Your insurance company will want the test numbers (called "CPT codes"). These are: 95921 (heart rate response to deep breathing), 95922 (valsalva maneuver and tilt), and 95923 (sudomotor testing). Your insurance company may also want the diagnosis numbers (called "ICD-9 codes"). You may obtain these from your referring physician. If your case is with the Ohio BWC we will instead require the allowed diagnosis code. Please write these in the spaces provided below:

	Diagnosis	ICD-9 Code
1
2
3

If you wish, you may also write in your insurance company information:

Company:

Contact:

Phone:

Cert#:

Date:

6. Please complete the information below:

Your name:	DOB:	UH no (if known):
Scheduler:	Appt Date:	Appt Time:

7. Physician's Referral

Reason for test:
MD Signature:	Name (print):	Phone:
Copy Report to:		Fax: