Schedule a Case · Delta Medical Monitoring

Procedure information

Fields marked * are required.

When

Date of surgery*Choose the surgery date.

Start time*

Choose a start time.

Est. duration of procedureHours : minutes

In patient / out patient

Inpatient Outpatient Unknown

Where & who

Hospital / facility*Enter the facility name.

Hospital NPINPI is 10 digits.

Surgeon*Enter the surgeon's name.

Surgeon NPINPI is 10 digits.

What

Procedure*Describe the procedure.

Diagnosis code (ICD-10)Can't find it? Describe the diagnosis in notes.

Diagnosis (if code unknown)

Modalities requested

SSEP TcMEP EMG Pedicle screw EEG BAEP Cranial nerve Your recommendation

Notes / special requestsUp to 250 characters

Patient information

If you don't have demographics yet, check the box and attach them later. We'll follow up.

Patient information unknown at this time

Name

First name

Middle name

Last name

Preferred name

Date of birth

Sex

Marital status

SSNOptional. Helps match records for billing.

Address

Address 1

Address 2

City

State

ZIP code

Phone

Mobile

Work phone

Home phone

Insurance & documents

We bill commercial plans, auto (PIP / no-fault) and workers' compensation carriers directly.

Coverage

Coverage type

Commercial Auto · PIP / No-fault Workers' comp Other / unknown

Insurance carrier

Plan type

Policy number

Pre-authorization #

Insurance note

Attachments

Add attachments Surgery orders, patient demographics, H&P and related documents

Confirmation

Office contact

Office phone

Office email for confirmations*Enter a valid email address.

Review & submit

Check the details below. You can edit any section before submitting.

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