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Practice Information
Practice Name*
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Attestation
Healthcare Provider 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 itself provide a diagnosis nor will it solely recommend a therapeutic treatment for this patient monitoring as listed above. I understand that the diagnostic testing provided will not provide a diagnosis nor will it solely recommend a therapeutic treatment for this patient. For Referring Providers that are also Interpreting Physicians, this Attestation will cover you under our PHI/HIPAA Business Associates Agreement.
Physician/Practice Administrator Signature
Date
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