How to Fill Out and Submit the ZOLL LifeVest Order Form

The ZOLL LifeVest order form is a one-page prescription a physician completes to order the wearable cardioverter defibrillator for a patient at temporary risk of sudden cardiac arrest. Download it from ZOLL’s ordering page at cardiac.zoll.com or ask a local ZOLL representative for a copy, complete the three sections (patient and indication, device settings, prescriber), and fax the signed form with the required clinical documents to 1-866-567-7615.¹ Getting each field right the first time is the difference between a device fitted before discharge and an order that stalls in ZOLL’s compliance queue.

Where to Get the Form and How to Submit It

The current medical order form is posted on ZOLL’s cardiac site as a PDF, and a ZOLL representative can also send a copy on request.² Complete it, gather the supporting clinical documents described further down, and fax the packet to 1-866-567-7615.¹

Two alternatives exist if the official form does not fit your workflow. A prescriber can write a chart order directly in the patient’s record — it must include the patient’s name, the date, an order for a “wearable defibrillator” or “LifeVest,” the duration in months, the device settings, a treatment plan regarding an ICD, and the prescriber’s signature and NPI — then fax it with the same clinical documentation. A physician or designee can also place a verbal order by calling ZOLL Customer Support at 1-800-543-3267; ZOLL staff complete the form and fax it back for signature. Verbal orders are not accepted for Medicare patients, so that route is limited to commercial and other non-Medicare coverage.¹

Section 1: Patient Information and Reason for LifeVest

The top of the form asks for the patient’s printed first and last name and date of birth.² Two clinical fields follow.

Estimated Start Date and Length of Need

The start date is the day you expect the patient to begin wearing the device, often the hospital discharge date. Below it, check one of three length-of-need options: four months, three months, or “Other” with a blank for a custom number of months. Leave this blank and ZOLL defaults the order to one month, which means submitting a new order to continue use beyond that.² The length you choose should carry the patient to the point of ICD reassessment: about 40 days after a heart attack, 90 days after revascularization surgery, and three to nine months for newly diagnosed non-ischemic cardiomyopathy.³

Reason for LifeVest

Check exactly one of six indications:²

Cardiac arrest due to ventricular fibrillation or sustained ventricular tachycardia.
Familial or inherited condition with sudden cardiac arrest risk, such as long QT syndrome or hypertrophic cardiomyopathy.
Myocardial infarction with an ejection fraction of 35 percent or below.
Dilated cardiomyopathy, including non-ischemic, with an ejection fraction of 35 percent or below.
ICD explantation — the patient previously had an implanted defibrillator that has been removed.
Other condition with high risk of ventricular tachycardia or fibrillation, described in a free-text field.

These six options track the Medicare coverage criteria for HCPCS code K0606, which is printed on the form. Selecting the checkbox that matches your clinical documentation makes prior authorization move faster.⁴

Section 2: Device Settings

The middle section sets three arrhythmia parameters. Each has a default that ZOLL applies if the field is left blank, and most prescribers accept the defaults unless the patient has a known rhythm pattern that calls for adjustment.²

VT heart rate threshold. Default 150 bpm, adjustable in increments of 10.
VF heart rate threshold. Default 200 bpm, adjustable in increments of 10.
Treatment energy. Default 150 joules for all five shocks, adjustable in increments of 25 between 75 and 150 joules, and you can set a different level for each of the five shocks if you want the device to escalate.

Section 3: Prescriber Information and Signature

The bottom of the form identifies the ordering physician and a contact person for follow-up questions. Fill in:²

Designated contact person — usually a nurse coordinator, PA, or office staff member ZOLL can reach with questions about the order.
Contact person’s phone number.
Prescriber’s printed first and last name.
Prescriber’s handwritten signature. The form states “Do Not Stamp.” Signature stamps and electronic auto-signatures are rejected.
Signature date.
Prescriber’s National Provider Identifier (NPI).

Check that the signature date matches or follows the date of the clinical assessment that supports the order. A signature dated before the echocardiogram or discharge summary raises a compliance flag and delays processing.

Clinical Documentation to Fax With the Form

The order form is not enough on its own. Every submission must include a hospital face sheet showing the patient’s demographics and insurance information, plus documentation that matches the indication you checked in Section 1.¹²

Cardiac arrest due to VF or sustained VT: a history and physical, progress note, consult note, or discharge summary; an EP study showing induced VF or sustained VT; and a treatment plan regarding ICD implantation.
Familial or inherited condition: a history and physical, progress note, consult note, or discharge summary; and a treatment plan regarding ICD implantation.
MI with EF ≤ 35 percent, or dilated cardiomyopathy with EF ≤ 35 percent: a history and physical, progress note, consult note, or discharge summary; a treatment plan regarding ICD implantation; and a report from the echocardiogram or other test that measured the ejection fraction.
ICD explantation: a history and physical, progress note, consult note, or discharge summary.
Other high-risk condition: a history and physical, progress note, consult note, or discharge summary; and a treatment plan supporting the risk condition.

The ejection fraction report is where orders most often stall. The report needs to state EF as a specific number (not “reduced”) and show the date the test was performed. An echocardiogram, cardiac MRI, or nuclear study all qualify.⁵ If the EF result is buried inside a multi-page echo report, flag or highlight the relevant page before faxing.

What Happens After You Fax the Order

Once ZOLL receives a complete, signed order with the supporting documents, their coverage team opens the insurance verification and prior authorization workflow. Medicare covers the LifeVest under HCPCS code K0606 for patients meeting one of four criteria: a documented episode of VF or sustained VT not caused by a reversible condition and not within the first 48 hours of a heart attack; a familial or inherited condition with high arrhythmia risk; prior MI or dilated cardiomyopathy with a measured EF of 35 percent or below; or a previously implanted defibrillator that has been explanted.⁴ Most commercial, state, and federal plans also cover the device.⁶

A missing EF number, an unsigned form, or a stamped signature stops the authorization from going out. Once the packet is clean, a ZOLL representative contacts the patient to schedule an in-person fitting, which often happens before or shortly after hospital discharge. For questions about a submitted order or to place a verbal order, ZOLL Customer Support is reachable at 1-800-543-3267.¹

1
ZOLL Medical Corporation. LifeVest Medical Order, Chart Order, and Verbal Order Instructions
2
ZOLL. ZOLL LifeVest Medical Order Form
3
ZOLL. LifeVest Medical Professional Frequently Asked Questions
4
Centers for Medicare & Medicaid Services. LCD – Automatic External Defibrillators (L33690)
5
Department of Veterans Affairs. LifeVest Patient Education Booklet
6
ZOLL. Ordering and Coverage for LifeVest