8886932401 2026

1. Click ‘Get Form’ to open the ZIO™ Patient Enrollment Form in the editor.
2. Begin by indicating whether the patient has used an iRhythm product before by selecting 'Yes' or 'No'.
3. Fill in the Account Information section, including Account Name, Phone, Fax, Address, City, State, and ZIP Code.
4. In the Patient Information section, enter the Patient Name (Last, First), Patient ID (if applicable), Birth Date, and complete the address fields. Ensure to provide both Primary and Secondary Phone numbers.
5. Select the patient's sex and indicate if they have a Pacemaker or Implanted Cardiac Defibrillator by checking 'Yes' or 'No'.
6. Complete the Service Information section by selecting the Monitoring Start Date and choosing between Zio™ Event Card or Zio™ Patch. Provide details for Managing Physician and Referring Physician if applicable.
7. Indicate whether iRhythm staff will provide enrollment service and if the device should be sent directly to the patient.
8. Lastly, select the reason for device prescription from the provided options.

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