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Get Video Eeg Request Form Inpatient Outpatient 24 Hrs 48 ... - Sch-prod Chsli
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How to fill out the VIDEO EEG REQUEST FORM INPATIENT OUTPATIENT 24 Hrs 48 ... - Sch-prod Chsli online
Filling out the VIDEO EEG REQUEST FORM is an essential step for individuals requiring either inpatient or outpatient services. This guide will provide clear, step-by-step instructions to ensure accurate completion of the form to facilitate timely medical evaluation.
Follow the steps to successfully complete the form.
- Press the ‘Get Form’ button to access the VIDEO EEG REQUEST FORM. This action will enable you to view and prepare the document for completion.
- Indicate whether the request is for an inpatient or outpatient service by selecting the appropriate checkbox. Choose the timeframe for the EEG (24 hrs, 48 hrs, or 72 hrs) by ticking the corresponding option.
- Provide the date of the request in the designated space, noting the current date to ensure timely processing.
- Complete the 'Requested by' section with the name of the individual filling out the form.
- Select the status of the request based on urgency by marking the appropriate checkbox (Emergency, Urgent, Rush, ASAP, or Routine).
- Fill in the names of the ordering doctor and referring doctor to establish the medical providers involved in the request.
- Enter the patient’s name and the Medical Record Number (MRN) in the indicated fields.
- Document the patient's age, gender, date of birth, and the contact person's details, including various phone numbers.
- Provide the insurance company details, including the policy number and group number, ensuring the insurance information is accurate.
- In the medical history section, describe any relevant medical conditions, current medications, and dosages that the patient is taking.
- Summarize the dates of any previous tests related to the patient's condition, including Video/EEG, MRI, CT, EEG, SPECT, and PET.
- Finally, be sure to fax the completed request along with any recent clinic notes or consultation reports to the designated fax number.
Complete the VIDEO EEG REQUEST FORM online today for a timely evaluation.
Prepare for Your Overnight Video EEG Before You Arrive: Please wash your hair with only shampoo (avoid creams, styling products, or oils) the night before or morning of the admission. Please Remember to Bring: Medications. Any medications that you need will need to be brought and administered by yourself.
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