Online Referral Form Ambulatory EEG Medical Necessity Form Patient InformationLast Name* First Name* DOB (Date of Birth)* Month Day Year GenderGenderFemaleMalePhone Number*Alt. Phone Number*Email Insurance Carrier* Address Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Referring PhysicianName* Phone*Email Fax NPI Patient DiagnosisMedicare Approved Diagnosis Codes*Select all that apply (hold command/cntrl to select multiple). F44.5G40.001G40.009G40.011G40.019G40.101G40.109G40.111G40.119G40.201G40.209G40.211G40.219G40.301G40.309G40.311G40.319G40.401G40.409G40.411G40.419G40.501G40.509G40.801G40.802G40.803G40.804G40.811G40.812G40.813G40.814G40.821G40.822G40.823G40.824G40.89G40.901G40.909G40.911G40.919G40.A01G40.A09G40.A11G40.A19G40.B01G40.B09G40.B19G93.1R25.0R25.1R25.2R25.3R25.8R25.9R40.0R40.4R41.82R55R56.1R56.9Requested ProcedureSection A* 95700 – EEG Hookup 95715 - Long Term vEEG, Intermittent Monitoring 95715 - Long Term vEEG, Intermittent Monitoring EEG Duration 24 Hours | 1 Day 48 Hours | 2 Days 72 Hours | 3 Days 120 Hours | 5 Days 168 Hours | 7 Days 95813 – Routine Extended EEG >1 hour 95813 – Routine Extended EEG >1 hour Required if last EEG was greater than 12 months agoOnly if required for Insurance approval Only if required for Insurance approval Other Other Other Procedure Special Instructions:Physician Reports/InterpretationSection B Send me daily tech summary & notification to access the EEG for reporting every 24 hours. Send Daily Notification Via: I will interpret the full study after completion.* I will interpret the full study after completion. Reading physician is different than referring physician Reading physician is different than referring physician Reading Physician Name* Comments:NEUROVATIVE WILL GENERATE A BILLING GUIDE SHEET REFLECTIVE OF THE COMPLETED STUDY & REPORTING REQUIREMENTS TO ASSIST IN SUBMITTING THE PROFESSIONAL COMPONENT FOR REIMBURSEMENT. 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 Routine EEG report(recent within 12 months for Medicare, Aetna, Tricare, and BCBS) Drop files here or Select files Accepted file types: jpg, pdf, png, xls, doc, docx, Max. file size: 15 MB, Max. files: 2. Latest Clinical Notes* Drop files here or Select files Accepted file types: jpg, pdf, png, xls, doc, docx, Max. file size: 15 MB, Max. files: 2. Patient Demographics & Medication List* Drop files here or Select files Accepted file types: jpg, pdf, png, xls, doc, docx, Max. file size: 15 MB, Max. files: 2. Copy of Insurance Cards Front & Back(if not included in Patient Demographics) Drop files here or Select files Accepted file types: jpg, pdf, png, xls, doc, docx, Max. file size: 15 MB, Max. files: 2. Physician SignaturePlease type signer's name.First Name* Last Name Submitted By* Submitted By Email* Ambulatory EEG Medical Necessity Form Patient InformationLast Name* First Name* DOB (Date of Birth)* Month Day Year GenderGenderFemaleMalePhone Number*Alt. Phone Number*Email Insurance Carrier* Address Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Referring PhysicianName* Phone*Email Fax NPI Patient DiagnosisMedicare Approved Diagnosis Codes*Select all that apply (hold command/cntrl to select multiple). F44.5G40.001G40.009G40.011G40.019G40.101G40.109G40.111G40.119G40.201G40.209G40.211G40.219G40.301G40.309G40.311G40.319G40.401G40.409G40.411G40.419G40.501G40.509G40.801G40.802G40.803G40.804G40.811G40.812G40.813G40.814G40.821G40.822G40.823G40.824G40.89G40.901G40.909G40.911G40.919G40.A01G40.A09G40.A11G40.A19G40.B01G40.B09G40.B19G93.1R25.0R25.1R25.2R25.3R25.8R25.9R40.0R40.4R41.82R55R56.1R56.9Requested ProcedureSection A* 95700 – EEG Hookup 95715 - Long Term vEEG, Intermittent Monitoring 95715 - Long Term vEEG, Intermittent Monitoring EEG Duration 24 Hours | 1 Day 48 Hours | 2 Days 72 Hours | 3 Days 120 Hours | 5 Days 168 Hours | 7 Days 95813 – Routine Extended EEG >1 hour 95813 – Routine Extended EEG >1 hour Required if last EEG was greater than 12 months agoOnly if required for Insurance approval Only if required for Insurance approval Other Other Other Procedure Special Instructions:Physician Reports/InterpretationSection B Send me daily tech summary & notification to access the EEG for reporting every 24 hours. Send Daily Notification Via: I will interpret the full study after completion.* I will interpret the full study after completion. Reading physician is different than referring physician Reading physician is different than referring physician Reading Physician Name* Comments:NEUROVATIVE WILL GENERATE A BILLING GUIDE SHEET REFLECTIVE OF THE COMPLETED STUDY & REPORTING REQUIREMENTS TO ASSIST IN SUBMITTING THE PROFESSIONAL COMPONENT FOR REIMBURSEMENT. 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 Routine EEG report(recent within 12 months for Medicare, Aetna, Tricare, and BCBS) Drop files here or Select files Accepted file types: jpg, pdf, png, xls, doc, docx, Max. file size: 15 MB, Max. files: 2. Latest Clinical Notes* Drop files here or Select files Accepted file types: jpg, pdf, png, xls, doc, docx, Max. file size: 15 MB, Max. files: 2. Patient Demographics & Medication List* Drop files here or Select files Accepted file types: jpg, pdf, png, xls, doc, docx, Max. file size: 15 MB, Max. files: 2. Copy of Insurance Cards Front & Back(if not included in Patient Demographics) Drop files here or Select files Accepted file types: jpg, pdf, png, xls, doc, docx, Max. file size: 15 MB, Max. files: 2. Physician SignaturePlease type signer's name.First Name* Last Name Submitted By* Submitted By Email*
