<p> PLACE LABEL HERE NEUROLOGY OUTPATIENT ORDERS Neurology scheduling: 678-312-4429 Neurology Fax: 678-312-2185 PLEASE CALL NEUROLOGY DEPARTMENT TO SCHEDULE ALL TESTS</p><p>Appointment date/time: ______GWINNETT MEDICAL CENTER (Lawrenceville) only Patient: ______SSN:______DOB:______Daytime phone: ______Evening phone:______Allergies:______</p><p>Medicare: Yes  No Insurance:______ Precertification number if required: ______</p><p>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.</p><p>CLINICAL INFORMATION / SIGNS / SYMPTOMS NO RULE OUTS ICD-9 CODES ______</p><p>Electromyography EEG 5 Sleep deprived EEG 8</p><p>1 Ambulatory EEG  24 Hours  48 Hours</p><p>2 Video EEG 24 hours (patient must be admitted to hospital by physician) -</p><p>2 Evoked Potentials 1</p><p>3 Brain stem auditory evoked response</p><p>) Visual evoked response </p><p>8 Somatosensory Evoked Potentials (SSEP) 7</p><p>6 Upper nerve SSEP (</p><p>Lower nerve SSEP :</p><p>O Nerve Conduction/ Electromyographic Studies (prior authorization required prior to scheduling) T</p><p>Upper extremity  Right  Left  Bilateral</p><p>X Lower extremity  Right  Left  Bilateral A</p><p>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 #):______</p><p>*1-19292* FORM 1-19292 REV. 11/2011 Page 1 of 1</p>