united diagnostics video ambulatory eeg express order … · melrose, ma quincy, ma providence, ri...

Patient Name ________________________________________ ❑ Male ❑ Female DOB _____ / _____ / _______ Patient Address Insurance _________________________ ID # _____________ Referring Physician ____________________________________ Address ______________________________________________ _____________________________________________ Cell Phone ____________________________________ Home Phone __________________________________ PLEASE PROVIDE US WITH A COPY OF THE FRONT & BACK OF INSURANCE CARD, PATIENT DEMOGRAPHICS, CLINICAL NOTES & ROUTINE EEG REPORT _____________________________________________ Phone # _______________________________________ Fax # ________________________________________ NPI # ________________________________________ REFERRING PHYSICIAN STATEMENT PHYSICIAN SIGNATURE DATE ❑ Long Term Ambulatory EEG Length of Monitoring Requested (Check one) CLINICAL HISTORY Check all that apply ❑ General Nonconvulsive Epilepsy ❑ Partial Epilepsy with Impairment ❑ Convulsion ❑ Syncope ❑ General Convulsive Epilepsy ❑ Partial Epilepsy w/o impairment ❑ Vertigo ❑ Transient Ischemic Attack Primary Diagnosis_____________________ Secondary Diagnosis __________________ Etiology_______________ ICD10 ________ EEG History ❑ REEG ❑ SDEEG ❑ A-EEG ❑ EMU RESULTS ❑ Normal ❑ Slowing ❑ Abnormal Findings___________________ TEST OBJECTIVE ❑ Differential Diagnosis ❑ Monitor Interictal ❑ Evaluate Epilepsy/Seizure Class ❑ Patient requires special assistance ❑ Video AEEG Study Please send routine EEG and chart notes with your referral ❑ 72 hours ❑ 48 hours ❑ ______ hours I certify that I am referring the above named patient to United Diagnostics for long term neurophysiological monitoring using the Home Monitoring system. I certify to the best of my knowledge this test and any interpretation is medically necessary in order to diagnose this patient. I understand that this test and any interpretation provided are intended only to supplement my diagnosis of this patient’s condition. G40.A01 G40.201 R56.9 R55 G40.309 G40.001 R42 435.30 Reader preference : ❑ Melrose, MA ❑ Quincy, MA ❑ Providence, RI ❑ At home setup ❑ Fax: VIDEO AMBULATORY EEG EXPRESS ORDER FORM 1.888.539.3001 United Diagnostics We do not currently accept BMC or Neighborhood Insurances E-mail _______________________________________

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Page 1: United Diagnostics VIDEO AMBULATORY EEG EXPRESS ORDER … · Melrose, MA Quincy, MA Providence, RI At home setup Fax: VIDEO AMBULATORY EEG EXPRESS ORDER FORM 1.888.539.3001 United

Patient Name ________________________________________

❑ Male ❑ Female DOB _____ / _____ / _______

Patient Address

Insurance _________________________ ID # _____________

Referring Physician ____________________________________

Address ______________________________________________

_____________________________________________

Cell Phone ____________________________________

Home Phone __________________________________

PLEASE PROVIDE US WITH A COPY OF THE FRONT & BACK OF INSURANCE CARD, PATIENT DEMOGRAPHICS, CLINICAL NOTES & ROUTINE EEG REPORT

_____________________________________________

Phone # _______________________________________

Fax # ________________________________________

NPI # ________________________________________

REFERRING PHYSICIAN STATEMENT

PHYSICIAN SIGNATURE DATE

❑ Long Term Ambulatory EEG

Length of Monitoring Requested (Check one)

CLINICAL HISTORY Check all that apply❑ General Nonconvulsive Epilepsy ❑ Partial Epilepsy with Impairment ❑ Convulsion ❑ Syncope ❑ General Convulsive Epilepsy❑ Partial Epilepsy w/o impairment ❑ Vertigo ❑ Transient Ischemic Attack

Primary Diagnosis_____________________Secondary Diagnosis __________________Etiology_______________ ICD10 ________

EEG History❑ REEG ❑ SDEEG ❑ A-EEG ❑ EMURESULTS❑ Normal ❑ Slowing❑ Abnormal Findings___________________TEST OBJECTIVE❑ Differential Diagnosis ❑ Monitor Interictal ❑ Evaluate Epilepsy/Seizure Class

❑ Patient requires special assistance❑ Video AEEG Study Please send routine EEG and chart noteswith your referral

❑ 72 hours ❑ 48 hours ❑ ______ hours

I certify that I am referring the above named patient to United Diagnostics for long term neurophysiological monitoring using the Home Monitoring system. I certify to the best of my knowledge this test and any interpretation is medically necessary in order to diagnose this patient. I understand that this test and any interpretation provided are intended only to supplement my diagnosis of this patient’s condition.

G40.A01G40.201

R56.9R55

G40.309G40.001

R42435.30

Reader preference :

❑ Melrose, MA ❑ Quincy, MA ❑ Providence, RI ❑ At home setup

❑

Fax:

VIDEO AMBULATORY EEGEXPRESS ORDER FORM

1.888.539.3001

United Diagnostics

We do not currently accept BMC or Neighborhood Insurances