march3,2009-appliedneuroscience.docVIP

Neurofeedback for CLINICAL DISORDER Preemptive Letter: Out-of-Network DATE Health Plan ADDRESS Re: Request for Authorization for EEG Biofeedback/Neurofeedback to Treat ADHD Dear Health Plan Authorization Dept: I am starting to treat Patient’s Name, who is diagnosed with ADHD, by using neurofeedback (NFB). NFB is a safe and effective treatment that improves the core symptoms for patients diagnosed with ADHD. Patient’s Name is covered by Health Plan, and he/she or his/her parent/ legal guardian has signed a confidentiality release and authorization form authorizing me to act as