New Account Registration

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Practice Information
Practice Name*
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Provider Information
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NPI
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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

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