MEG Patient Referral Form

Please fax clinic note, EEG, and MRI report to 205-801-8169 to ensure we have all details needed for insurance approval.

Patient Name(Required)

First Middle Last

Date of Birth(Required)

ICD (Dxs)(Required)

Gender(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Primary Phone #(Required)

Alternate Phone #

MEG Tests Requested & Insurance Information

Specific tests & insurance information are required fields

MEG Test Requested(Required)

Epilepsy (CPT 95965)

Language (CPT 95966/7)

Somotosensory (CPT 95966 or 95967)

Visual (CPT 95966/7)

Auditory (CPT 95966/7)

Does the patient have a vagal nerve stimulator, a deep-brain stimulator or cochlear implant?(Required)

Yes

Insured's Name

First Middle Last

Insured's Date of Birth

Primary Insurance(Required)

Claims Address(Required)

Street Address Address Line 2 City State ZIP Code

Insurance Phone #(Required)

Policy & Group #(Required)

Secondary Insurance

Claims Address

Street Address Address Line 2 City State ZIP Code

Insurance Phone #

Policy & Group #

Is the patient under 18 or developmentally delayed?(Required)

Yes

Patient Contact or Parent/Guardian

Required for under 18 or developmentally delayed.

Name(Required)

First Last

Relation to Patient(Required)

Primary Phone #(Required)

Referring Doctor Information

Referring Doctor (Required for return of results)(Required)

First Last

NPI Number(Required)

Email(Required)

Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone #(Required)