Physician Referral Forms

Thank you for referring your patient to the USA SouthCEP Epilepsy Monitoring Unit.

The EMU requires certain paperwork to be completed before patient admission. The following is a list of forms and information our staff and physicians need to properly admit and care for your patient. If your patient's insurance company requires a Prior Authorization or pre-certification, this information will need to be included in the Admission Cover Sheet.

Additionally, there is some information your patient must be aware of prior to admission. Please give this EMU Information Letter to patient with the date of EMU.

The following forms and documents must be completed and faxed to the EMU unit at 251-445-9046. 

  • Patient physical and history
  • Patient demographics
  • Diagnosis
  • Clinic notes from previous six months

If available, please include:

  • MRI
  • CT
  • EMG
  • Previous EMU
  • Blood work

The following forms and documents must be completed and faxed to the USAMC Patient Access department at 251-471-7275.

  • Patient's Driver's License
  • Patient's Insurance card
  • Medicaid or Medicare referral (if applicable)         

 

For assistance in completing the EMU Admission Cover Sheet or for any other questions, please contact:

Tommy Vernon or Tiffany Folse at 251-445-9048

 

Email Newsletters

Connect With Us