Get Legacy Neurodiagnostic Services - Legacyhealth

This guide will assist you in completing the Legacy Neurodiagnostic Services form accurately and efficiently. Follow the steps outlined below to ensure all necessary information is provided for effective processing.

Follow the steps to fill out the form online.

1. Press the ‘Get Form’ button to access the document and open it in your preferred online platform.
2. Select the appropriate location for the service you are referring to by marking the corresponding checkbox.
3. Provide the patient’s full name in the designated space, and indicate their gender by selecting ‘Male’ or ‘Female’.
4. Enter the patient’s phone number and date of birth in the respective fields.
5. Fill in the patient’s address and choose the primary language spoken by selecting ‘English’ or specifying another language.
6. In the section labeled ‘Indication for EEG’, briefly include relevant medical history and current medications.
7. Complete the insurance information by entering the diagnosis code and description, along with the preauthorization number.
8. Fill in the insurance company name, member ID, group ID, subscriber name, subscriber date of birth, and their relation to the patient.
9. Choose one of the EEG services by selecting the relevant option, including Standard EEG, Sleep-Deprived EEG, and others.
10. If applicable, indicate which type of evoked potentials are needed by checking the suitable option.
11. Provide any special instructions, such as sedation requests or duration, in the respective section.
12. Specify whether the patient will call to schedule the EEG or if the EEG team will contact the patient.
13. Fill in the referring physician's name, clinic name, and obtain their signature along with the date.
14. Finally, save your changes, download the completed document, print it, or share it as required.

Complete your documents online to ensure a smooth and efficient process.