Fields marked with an * are required fields.
Patient Information
Sex* :
State* :
Additional Information
NOTE: If patient has BCBS-IL, Molina Healthcare and any IL-Medicaid HMOs as primary insurance, please send patient’s medical records so EEG test can be pre-authorized.
Diagnosis Code * :
EEG Duration * :
If Until Event Occurs is selected, please select the maximum number of days :
Additional Monitoring :
Check all that are applicable.VideoECGT1 T2A1 A2Fz/Pz
Physician Signature :
By checking the box, you are indicating that you are the referring physician and are authorizing the EEG study for this patient.
