EEG Referral Form — Alaska Neurodiagnostics Specialists LLC

Please PRINT out FORM and FAX the required documents to:

1-800-920-5401

ANS EEG Referral Form

Alaska Neurodiagnostics Specialists, LLC WILL GENERATE A BILLING GUIDE SHEET REFLECTIVE OF THE COMPLETED vEEG STUDY.

To process without delay please Fax the following to 1-800-920-5401

A completed EEG referral form
Routine EEG report (recent within 12 months, if applies)
Copy of Insurance Cards front/back (if not included in patient Demos)
Latest Clinical Notes
Patient Demographics & Current Medication List