- PRIA Enrollment

Abbott CardioMEMS Patient Therapy Access Patient Appeals Program

Quality of Life Patient Survey

If you have, or suspect you may have, an illness or condition that you believe requires medical attention, we recommend you call your treating physician. The answers you provide to this survey will not be communicated to you treating physician(s).

If you believe you are experiencing a medical emergency, please call 911 (or your local medical emergency number) or seek immediate care from the nearest hospital emergency room.

CardioMEMS QOL

Patient Information

Patient's Name *

Patient's Name

First

First

Last

Last

Patient's Date of Birth *

Quality of Life Patient Survey

Please select any heart failure symptoms that you experience:

Swelling

Shortness of breath

Fatigue

Fainting

OtherOther

Can you perform your daily activities, such as showering/bathing, dressing, cooking, eating, or household chores without significant difficulty due to heart failure symptoms?

Yes

No (If No, please provide examples of your limitations below)No (If No, please provide examples of your limitations below)

Have your heart failure symptoms affected your level of independence when managing your daily activities?

No

Yes (If yes, please provide examples below)Yes (If yes, please provide examples below)

Have your heart failure symptoms listed above affected your sleep quality?

No

Yes (If yes, please explain below)Yes (If yes, please explain below)

Are there any specific activities or hobbies that you are no longer able to participate in due to the heart failure symptoms indicated by you above?

No

Yes (If yes, please provide examples) Yes (If yes, please provide examples)

How many social events have you had to say no to due to your heart failure diagnosis in the last 3 months?

Are there any additional comments or concerns you would like to share about how your heart failure diagnosis has affected your quality of life?

If you are human, leave this field blank.

Disclaimer:
Abbott and its third-party representatives engaged in providing patient appeal services to patients prescribed with CardioMEMS by their treating physician (collectively, “Abbott”), disclaim any and all liability to any party for any and all damages arising directly or indirectly from the answers herein provided. The information herein provided is not intended to create, transfer, or assign any responsibility from the patient’s treating physician to Abbott. Abbott does not make and representations or warranties with respect to the accuracy or completeness of the answers herein provided.

IMPORTANT SAFETY INFORMATION

Rx Only
Brief Summary: Prior to using these devices, please review the Instructions for Use for a complete listing of indications, contraindications, warnings, precautions, potential adverse events and directions for use.

CardioMEMS™ HF System Indications and Usage: The CardioMEMS HF System is indicated for wirelessly measuring and monitoring pulmonary artery pressure and heart rate in NYHA Class II or III heart failure patients who either have been hospitalized for heart failure in the previous year and/or have elevated natriuretic peptides. The hemodynamic data are used by physicians for heart failure management with the goal of controlling pulmonary artery pressures and reducing heart failure hospitalizations.

CardioMEMS™ HF System Contraindications: The CardioMEMS™ HF System is contraindicated for patients with an inability to take dual antiplatelet or anticoagulants for one month post implant.

CardioMEMS™ HF System Potential Adverse Events: Potential adverse events associated with the implantation procedure include, but are not limited to, the following: air embolism, allergic reaction, infection, delayed wound healing, arrhythmias, bleeding, hemoptysis, hematoma, nausea, cerebrovascular accident, thrombus, cardiovascular injury, myocardial infarction, death, embolization, thermal burn, cardiac perforation, pneumothorax, thoracic duct injury and hemothorax.

Disclaimer
This material and the information contained herein is for general information purposes only and is not intended, and does not constitute, legal, reimbursement, business, clinical, or other advice. Furthermore, it is not intended to and does not constitute a representation or guarantee of reimbursement, payment, or charge, or that reimbursement or other payment will be received. It is not intended to increase or maximize payment by any payer. Abbott makes no express or implied warranty or guarantee that the list of codes and narratives in this document is complete or error-free. Similarly, nothing in this document should be viewed as instructions for selecting any particular code, and Abbott does not advocate or warrant the appropriateness of the use of any particular code. The ultimate responsibility for coding and obtaining payment/reimbursement remains with the customer. This includes the responsibility for accuracy and veracity of all coding and claims submitted to third-party payers. In addition, the customer should note that laws, regulations, and coverage policies are complex and are updated frequently and is subject to change without notice. The customer should check with its local carriers or intermediaries often and should consult with legal counsel or a financial, coding, or reimbursement specialist for any questions related to coding, billing, reimbursement, or any related issues. This material reproduces information for reference purposes only. It is not provided or authorized for marketing use.

Information contained herein for DISTRIBUTION in the U.S. ONLY.

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