Neurology Outpatient Orders

PLACE LABEL HERE NEUROLOGY OUTPATIENT ORDERS Neurology scheduling: 678-312-4429 Neurology Fax: 678-312-2185 PLEASE CALL NEUROLOGY DEPARTMENT TO SCHEDULE ALL TESTS

Appointment date/time: ______GWINNETT MEDICAL CENTER (Lawrenceville) only Patient: ______SSN:______DOB:______Daytime phone: ______Evening phone:______Allergies:______

Medicare: Yes  No Insurance:______ Precertification number if required: ______

A note to all Physicians: Tests should only be ordered that are medically necessary for the diagnosis, symptoms and/or treatment. The patient may be billed for tests that are not deemed necessary by payers. Please submit ALL (appropriate) clinical indications for ALL test(s) ordered.

CLINICAL INFORMATION / SIGNS / SYMPTOMS NO RULE OUTS ICD-9 CODES ______

Electromyography EEG 5 Sleep deprived EEG 8

1 Ambulatory EEG  24 Hours  48 Hours

2 Video EEG 24 hours (patient must be admitted to hospital by physician) -

2 Evoked Potentials 1

3 Brain stem auditory evoked response

) Visual evoked response

8 Somatosensory Evoked Potentials (SSEP) 7

6 Upper nerve SSEP (

Lower nerve SSEP :

O Nerve Conduction/ Electromyographic Studies (prior authorization required prior to scheduling) T

Upper extremity  Right  Left  Bilateral

X Lower extremity  Right  Left  Bilateral A

F Comments:______The procedure will not be performed in the absence of the completed form including the appropriate diagnosis and/or ICD-9 code supporting the ordered procedure. Ordering physicians are responsible for the accuracy of the information provided. Please fax form to 678-312-2185 and have patient bring this form on the date of service. Physician (please print):______Physician ID #:______Physician signature:______Date:______ Telephone  Fax Results to (phone or fax #):______

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