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Ambulatory EEG w/ Video Order Form

Patient Demographics
Name*
First Last
DOB*
Date Format: MM slash DD slash YYYY
SSN (optional)
Address*
Street Address City State ZIP Code
Phone*
Email*
Clinical History
Medically Necessary Diagnosis Codes – Check All Applicable, Must Select At Least One*
- F44.5 - Conversion disorder (Functional neurological symptom disorder)
- F48.8 - Nonpsychotic Mental Disorders
- G40.001-G40.919 - Seizures / Epilepsy
- I67.8X - Cerebrovascular Diseases
- R00.0 - Tachycardia
- R25.1 - Tremors
- R25.2 - Cramp & Spasm
- R25.8 - Abnormal Involuntary Movements
- R40.4 - Transient alteration of awareness
- R41.0 - Disorientation
- R41.82 - Altered Mental Status
- R41.3 - Memory loss / Amnesia
- R42 - Dizziness / Vertigo (Spells)
- R55 - Syncope and collapse (Fainting)
- R56.1 - Post traumatic seizures
- R56.9 - Unspecified convulsions
- R94.XX - Abnormal EEG
- S06.2X0A-S06.2X9S - Traumatic Brain Injury
- Other
Other*
History
Medications
Order
Ambulatory EEG w/ Video Duration (Check One):*
Previous EEG*
If no previous EEG listed above, Routine EEG will be performed • All procedures Include Digital Spike and Seizure Analysis and ECG
Ordering Physician
Physician Name*
First Last
Physician Statement: I certify that I am referring the above named patient 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 recommend a therapeutic treatment for this patient.
Physician Signature*
Date Ordered*
Date Format: MM slash DD slash YYYY
File Upload
Drop files here or

Accepted file types: pdf, jpg.
Please upload the medical records for this patient here.

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Testing Order Form

Services
Coverage Area
FAQ
Employment
Contact
Online Bill Pay
Complaints
New Accounts
Testing Order Form

Ambulatory EEG w/ Video Order Form

Patient Demographics

Clinical History

Order

Ordering Physician