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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.