VIDEO EEG ORDER FORM

(1) Patient Demographics – All Fields Required

First Name

Last Name

Date

Gender

Address

City

State

ZIP

Primary Phone (H) (C)

Other Phone (H) (C)

Primary Insurance

ID #

Group #

Secondary Insurance

ID #

Group #

(2) ICD-10 Codes to Support Medical Necessity for Video EEG Monitoring

If Other, specify here

3) Has a Video ( Routine or Long-Term ) EEG Been Completed Within the Past Year?

Yes - If checked, please provide a copy of the test results with this order.

No - If checked, a routine video EEG (< 2 hr) procedure will need to be ordered in addition to the long-term video EEG when and/or as required by most payors.

(4) Procedure(s) Ordered - PLEASE PROVIDE: CLINICAL NOTES, PATIENT DEMOGRAPHICS, AND COPY OF INSURANCE CARD (Front & Back)

Routine Video EEG: (< 2 hr) A Video EEG has NOT been completed within the past year

* Long-Term Video EEG

Type:

Inpatient Epilepsy Monitoring Unit

Ambulatory at Patient's home

Monitoring Length (Duration): Up to 7days

* Cardiac monitoring with limited lead EKG will be concurrently done with all video EEG studies.

(5) Ordering Physician

Physician Name

Office Phone

Office Fax

Address

City

State

Zip

NPI #

Office Contact

Physician Statement: I certify that I have examined the above-named patient and determined that the above-ordered routine / long-term / Video EEG tests are required for proper diagnosis to guide treatment, and are medically necessary.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Physician Signature

Date Ordered

Your information will be encrypted.