Menu HomeAbout Us About Us Our Coronavirus Policy Our Providers Our Neurodiagnostic Technicians Affiliated ServicesLocationsEMG/NCS Information EMG/NCS Information Why it’s best to test EMG & NCS together Patient Resources Forms Patient Intake Form Consent Form Formularios de Consentimiento COVID-19 – Patient Screening COVID-19 Waiver COVID-19 Waiver – Español Personal Injury Lien – Patients Attorney Medical Lien Acknowledgement Interpreting & Disclosure Insurance Pending Insurance Identified Privacy Notice Conditions Tested LocationsFor Providers Why choose Precision Medical Group? For Providers Instructions to refer a patient Insurances We Accept Locations EMG Testing Referrals Newsletter SignupNewsContact UsFeedback Call Us Find a Location EMG Testing Referral Form In addition to this form, for scheduling, you can always call (855) EMG-NCV1 | Fax 949-955-0220 | Email Referrals@pomg.net Download a PDF version here. Referral Source (Facility Name):(Required)Referral Coordinator:(Required) First Last Today's Date:(Required) MM slash DD slash YYYY FAX and/or EMAIL (To send appt letter and report):(Required)Dr. Name:(Required) First Last Dr. Phone(Required)Patient Name:(Required) First Last Patient Date of Birth:(Required) MM slash DD slash YYYY Diagnosis(es):(Required)EMG/NCV + Consultation and Report:(Required)(CPT 99201-99205, 95907-95913, 95886-95887, 99358, 95923, 95937, WC007 - Codes and units TBD by testing Dr. at time of exam) Right Left Bilateral Upper Extremity Lower Extremity Other Please describe your "Other" choice below:(Required)Choose one below:(Required) AME QME PANEL QME Work Comp PI PPO Medicare Cash Follow-up Appointment Date:(Required) MM slash DD slash YYYY Patient Phone:(Required)Comments:M.D. Signature(Required) First Last Thank you for your referrals!Date of Signature:(Required) MM slash DD slash YYYY Marketer:(Required)Either your currently assigned facilitator or the one that serves the area in which your office is. Esteban Galvez - Orange County, San Diego, Desert Cities George Santos - Los Angeles, South Bay Melanie Greene - San Fernando Valley, Inland Empire, Hollywood, L.A. North of 101 Include: 1. Demo, 2. Authorization or RFA and Report if we are submitting. Saturday appointments available!Only PDF files may be uploaded to this server with a 5 MB individual file size limit. Drop files here or Select files Accepted file types: pdf, Max. file size: 5 MB. CAPTCHA
