To process without delay please include the following:
- Routine EEG report(recent within 12 months for Medicare, Aetna, Tricare, and BCBS)
- Copy of Insurance Cards front/back (if not included in patient Demos)
- Latest Clinical Notes
- Patient Demographics & Medication List
(recent within 12 months for Medicare, Aetna, Tricare, and BCBS)
(if not included in Patient Demographics)
Physician Signature
Please type signer's name.
