CAC Requests – TMH DO LLC

To request a prescription for scheduling your Coronary Artery Calcium Scan, please complete the form
Once submitted, the prescription will be sent within two business days to the facility you indicate on the form.
You will receive test result notifications from Dr. Husty’s office, and may also view your results through the facility portal if you have an account set up.
Remember it is important to follow up with your physician if you are instructed to do so.
If you have a zero score, no follow-up is required.

Patient Information

Request a Prescription for a Coronary Artery Calcium Scan. Thank you for completing this form.

The cost is not covered by insurance. Please do not provide your insurance information. Please advise the facility that you are self pay.

Department Affiliation

Relationship to Department

Department Employee Family Member Friend

Requested Facility

Advent Health Altamonte - Cost $100.00 HCA Florida Lake Monroe Hospital - Cost $110.00 Orlando Health Lake Mary Hospital - Cost $50 (Fire Department and Law Enforcement employees only)

First Name

Last Name

Age

Date of birth

Phone

Address

City

State

Postal code

Do You Have a Cardiologist

Yes No

To Schedule Your CAC Scan:

Advent Health Altamonte: 407-303-2250

HCA FL Lake Monroe: 888-897-2106

Orlando Health Lake Mary: 321-842-5630

You will also receive these phone numbers in your e-mail confirmation. Thank you.