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Ambulatory EEG Order Form
FAQ
New Account Registration
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Employment
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Ambulatory EEG w/ Video Order Form
Thank you for your interest in working with NeuLine Health. Please complete the form below to submit your EEG testing order:
Ordering Provider
Your Practice Email for Order Confirmation
*
Patient Demographics
Name
*
First
Last
DOB
*
Date Format: MM slash DD slash YYYY
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
Patient's Phone Number
*
Patient's Email (optional)
Patient's Clinical History
Medically Necessary Diagnosis Codes – Check All Applicable, Must Select At Least One
*
F43.10 - Post Traumatic Stress Disorder (PTSD)
F44.5 - Conversion Disorder w/ Seizures
F48.8 - Nonpsychotic Mental Disorders
F51.8 - Sleep Disorders
G40.001-G40.919 - Seizures
G47.00, G47.30, G47.9 - Sleep Disorders
I67.81-I67.85, I67.89 - Cerebrovascular Diseases
R00.0 - Tachycardia
R06.81 - Apnea
R25.1 - Tremors
R25.2 - Cramp & Spasm
R25.3- Fasciculation (Involuntary Muscle Contractions)
R25.8 - Abnormal Involuntary Movements
R40.4 - Transient alteration of awareness
R41.0 - Disorientation
R41.82 - Altered Mental Status
R41.3 - Memory loss / Amnesia
R45.1 - Restlessness & Agitation
R55 - Syncope and collapse (Fainting)
R56.1 - Post traumatic seizures
R56.9 - Unspecified convulsions
R94.01 - Abnormal EEG
S06.2X0A-S06.2X9S - Traumatic Brain Injury
Other
Other Diagnosis Code(s)
History
Medications
Order
Ambulatory EEG w/ Video Duration (Check One):
*
Select
72HR (Standard)
24HR
48HR
96HR
120HR
2HR (in-office only)
ROUTINE EEG (UNDER 2HR)
Previous EEG
*
Select
Not Applicable
Routine EEG (Last 3 Months)
Ambulatory EEG (Last 12 Months)
Epilepsy Monitoring Unit Stay (Last 12 Months)
Referring Provider
Provider Name
*
First
Last
Provider Signature
*
Acknowledgement
*
Healthcare Provider Statement:
I certify that I am referring the above-named patient for electroencephalographic (EEG) monitoring (routine EEG, 72HR ambulatory EEG with video) 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 recommend a therapeutic treatment for this patient.
File Upload: Medical Records
Drop files here or
Accepted file types: pdf, jpg, jpeg.
Please attach a copy of the patient demographics, front and back of insurance card, complete medication list, clinical notes, any previous neurological imaging/reports and previous Routine EEG report (if applicable).