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:

Patient Demographics

Name(Required)
Address(Required)
Please attach a copy of the patient demographics, front and back of insurance card, complete medication list, clinical notes and date of routine EEG.
Drop files here or
Max. file size: 256 MB.


    Clinical History

    Medically Necessary Diagnosis Codes(Required)


    Order

    Previous (if applicable, check all that apply)
    Results
    If no previous REEG is listed above OR one is listed and the results are not provided, I understand a Routine EEG will be performed prior to the 72-HR AEEG and, under those circumstances, I am specifically ordering the Routine EEG to be performed prior to the Ambulatory EEG. *Please provide results for previous test(s).


    Ordering Healthcare Provider

    Healthcare Provider Statement: I certify that I am referring the above-named patient for electroencephalographic (EEG) monitoring (routine EEG, 72-HR ambulatory EEG with video) 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.
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