Toggle navigation
(844) 212-5321 x2
support@neulinehealth.com
Toggle navigation
Services
Ambulatory EEG Order Form
FAQ
New Account Registration
Services
About
Employment
Online Bill Pay
Contact
Blog
Services
Ambulatory EEG Order Form
FAQ
New Account Registration
Services
About
Employment
Online Bill Pay
Contact
Blog
Go
New Account Registration
Distributor Information
Name/Company
*
Phone
*
Email
*
Enter Email
Confirm Email
Practice Information
Practice Name
*
Healthcare Specialty
*
Select
Behavioral Health
Cardiology
Chiropractic
Ear Nose & Throat (ENT)
Hematology
Home Health
Hospitalist
Internal Medicine
Long Term Acute Care (LTAC)
Neurology
OB/GYN
Oncology
Podiatry
Primary Care
Psychiatry
Urgent Care
Other
Phone
Fax
Address
*
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Practice Contact
*
Practice Contact Email
Practice Hours of Operation
Payer Mix (select all that apply)
*
Commercial
Medicare
Medicaid
Tricare
Workers Compensation
Provider Information
Name
NPI
Name
NPI
Name
NPI
Name
NPI
Name
NPI
Order Information
Send Results Via
Fax
Email
Attestation
Physician Statement: I/we certify that I/we am/are referring patients for long-term electroencephalographic (EEG) monitoring, or video long-term EEG monitoring as listed above, and to the best of my knowledge this test is medically necessary in order to diagnose the patient. I understand that the diagnostic testing provided will not provide a diagnosis nor will it solely recommend a therapeutic treatment for this patient.
Physician/Practice Administrator Signature
Date
Date Format: MM slash DD slash YYYY