Referral Form for Providers

Download referral form for Neurology Specialty Healthcare services. This form is intended for patients, caregivers, and healthcare providers to ensure accurate and timely neurological care.

Instructions

Download the Form

Download the appropriate referral form for the patient.

Complete the Information

Fill in all required patient and guardian information accurately.

Submit the Form

Submit the completed form via fax, email, or in person as instructed.

Neurology Specialty Healthcare – Form

Download the required neurology form below. Please complete all applicable sections before submission.

Neurology Referral Form PDF Document

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Web Referral Form

Neurology Specialty

1940 116th Ave NE, STE 200B, Bellevue, WA 98004
Tel: 206-486-2926 | Fax: 833-764-3518 | Email: referral@neurologyspecialty.com

1. Patient Information *

Name: DOB:

Gender: Parent/Guardian:

Primary Phone: Insurance Provider:

Member ID: Subscriber Name:

Subscriber DOB:

2. Referring Provider Information * Provider Name: Clinic Name: Phone: Fax:

3. Neurology Referral *

Please Select..

▶ Consult Referral
- ▶ Pediatric Neurology
  - Seizure / epilepsy evaluation (New: 99203–99205 / Established: 99213–99215)
  - Developmental delay (New: 99203–99205 / Established: 99213–99215)
  - Headaches / migraines (New: 99203–99205 / Established: 99213–99215)
  - Abnormal movements / tics (New: 99203–99205 / Established: 99213–99215)
  - Cerebral palsy (New: 99203–99205 / Established: 99213–99215)
  - Neuromuscular disorder (New: 99203–99205 / Established: 99213–99215)
  - Regression (New: 99203–99205 / Established: 99213–99215)
  - Neurogenetic disorder (New: 99203–99205 / Established: 99213–99215)
  - Hypotonia / hypertonia (New: 99203–99205 / Established: 99213–99215)
  - Others
- ▶ Adult Neurology
  - Stroke / TIA (New: 99203–99205 / Established: 99213–99215)
  - Epilepsy (New: 99203–99205 / Established: 99213–99215)
  - Headache disorders (New: 99203–99205 / Established: 99213–99215)
  - Multiple sclerosis (New: 99203–99205 / Established: 99213–99215)
  - Parkinson’s / movement disorder (New: 99203–99205 / Established: 99213–99215)
  - Peripheral neuropathy (New: 99203–99205 / Established: 99213–99215)
  - Cognitive decline / dementia (New: 99203–99205 / Established: 99213–99215)
  - Myasthenia gravis (New: 99203–99205 / Established: 99213–99215)
  - ALS (New: 99203–99205 / Established: 99213–99215)
  - Others
▶ Procedure / Test Referral
- ▶ Pediatric Neurology
  - EEG – 95816
  - Prolonged EEG – 95812
  - Video EEG monitoring – 95951
  - Ambulatory EEG – 95812
  - Brain MRI – 70553
  - Spine MRI – 72158
  - Lumbar puncture – 62270
  - ▶ EMG / nerve conduction study – 95907 / 95886
    - Right Arm – 95909, 95860
    - Right Leg – 95908, 95860
    - Left Arm – 95909, 95860
    - Left Leg – 95908, 95860
    - Both Arms – 95911, 95861
    - Both Legs – 95810, 95861
    - Others
  - Evoked potentials – 95925
  - Botox injections (spasticity) – 64612
  - Baclofen pump evaluation – 62360
  - VNS evaluation – 61885
  - Ketogenic diet program – 99214
  - Others
- ▶ Adult Neurology
  - EEG – 95816
  - ▶ EMG / nerve conduction study – 95907 / 95886
    - Right Arm – 95909, 95860
    - Right Leg – 95908, 95860
    - Left Arm – 95909, 95860
    - Left Leg – 95908, 95860
    - Both Arms – 95911, 95861
    - Both Legs – 95810, 95861
    - Others
  - Brain MRI / MRA – 70553 / 70544
  - Spine MRI – 72158
  - Lumbar puncture – 62270
  - Autonomic testing – 95925
  - Botox (migraine, dystonia) – 64612
  - Nerve blocks – 64450
  - DBS / VNS evaluation – 61885
  - Intrathecal pump – 62360
  - Others

4. Diagnosis * ICD10:

5. Special Instructions

6. Attachments Front/Back copy of Insurance Card Most recent clinic notes and relevant diagnostic results (Labs, Imaging, EEGs) Other

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