Neurodiagnostics Referral Form

Kern Medical 1700 Mount Vernon Avenue Bakersfield, CA 93306 Fax: 661.862.4940 Neurodiagnostics Referral Form Patient Name (Last Name, First Name, Middle Initial) Date Gender □ Male □ Female Patient preferred language for healthcare communication Date of Birth Patient Home Telephone Patient Alternative Telephone Patient Home Address Patient insurance company and plan(s) Authorization Number: Referral Form: Referring Provider Name (Last Name, First Name, Middle Initial) Referring Provider Contact Telephone Referring Provider Fax Referring Provider Address Patient’s Primary Care Provider (Last Name, First Name, Middle Initial) Procedure Requested: □ Routine EEG (REEG) - 20 Minutes (95816) □ Extended EEG - 1-2 Hours (95813) □ Extended EEG Greater than 2 Hours (95713) □ Long-Term EEG Recording (95716) □ Long-Term Ambulatory (Outpatient) EEG Recording (95953) EMU or Critical Continuous EEG (CCEEG) Length of Monitoring (select one): □ 24 HR □ 48 HR □ 72 HR □ 96 HR □ 120 HR □ ________ HR *Please attach last progress note, history and physical, insurance cards, demographics, any associated imaging. Provider Signature Please fax referral form and records to 661.862.4940 NEURODIAGNOSTICS Kern Medical offers the following EEG and EMU services Indications for routine Indications of Ambulatory Indications of VEEG study in How to Refer Patients to EEG VEEG EMU the EMU • After new onset seizure Ambulatory • Determine whether spells • Referrals can be arranged electroencephalography are epileptic seizures (spell by calling the Kern Medical • For diagnosing seizure Vs (EEG) is considered medically classification or differential Epilepsy Center. We non-seizure necessary for the diagnosis diagnosis) require a written request for • Classification of epilepsy and management of seizure consultation. • Identify the type of seizures activity when ANY of the • Investigating periods of occurring in individual with • We ask physicians and following criteria is met: altered awareness known epilepsy (seizure/ patients to provide as much • Evaluation of dementia • Inconclusive routine EEG syndrome and classification of the following information as possible in the referral • Suspected case of • Suspected epilepsy • Localize the seizure focus » encephalitis when the history, clinical for consideration of epilepsy Initial/latest clinic examination, and routine surgery (presurgical evaluation with history EEG are inconclusive evaluation) and physical Indications of Critical Care CVEEG • Suspected seizures of sleep • Monitor seizure frequency » Current list of medications disturbances (seizure quantification) with dosages » Last four or five clinic • Diagnosis of Nonconvulsive • Individual with confirmed • Adjust medications to notes – any information Seizures, Nonconvulsive epilepsy who is experiencing control seizures (medication concerning the reason for Status Epilepticus, and Other suspected non-epileptic adjustment) events referring the patient for Paroxysmal Events • Differentiate between evaluation • Assessment of efficacy of • Classification of seizure seizures and medications » Reports on EEG tests therapy for seizures and type for the selection or effects performed status Epilepticus adjustment of anti-epileptic medication » CDs of any head MRIs • Identification of Cerebral and/or location of MRIs Ischemia • Exclusion of non- neurological causes of » Any recent, relevant lab • Assessment of Severity seizure-like activity work of Encephalopathy and Prognostication • Seizures which are » Insurance information precipitated by naturally occurring cyclic events or » Patient data (contact environmental stimuli which information, date of birth, are not reproducible in the mailing address) hospital or clinic setting » Referring provider national provider identifier (NPI) Kern Medical HARI VEEDU, MD 1700 Mount Vernon Attending Neurologist and Medical Director Avenue Kern Medical Epilepsy Center Bakersfield, CA 93306 Dr. Veedu is board-certified in Neurology, board-certified in P: 661.862.4928 Clinical Neurophysiology, and board-certified in Epilepsy. F: 661.862.4940 He is a member of the American Academy of Neurology, the American Clinical Neurophysiology Society, and KernMedical.com American Epilepsy Society..

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