Specialty Medication Clinic - External Referral

Specialty Medication Clinic -

External Referral

Date of referral*

Patient Information

Patient name*

Patient's Pronouns*

Patient's Address*

Patient's Email

Patient's Phone*

Phone

Patient's D/O/B*

Patient's Social Security #

Health Insurance Carrier*

Insurance ID #*

Insurance Tel. #

Phone

Secondary Insurance Details

Patient Demographics

Other Language

Presenting Problem(s)

Diagnosis*

Medication being requested

esketamine (intranasal) clinic

Does client meet criteria for treatment resistant depression as defined by CMS? (two medication trials in two categories, during the most recent depressive episode)*

Select or enter value

If yes, please provide the medication names, dosage, and dates of use?*

Medication 1 Name

Medication 1 dosage*

Medication 1 dates of trial*

Medication 2 Name*

Medication 2 dosage*

Medication 2 dates of trial*

Spravato treatment is contraindicated in patients with the following conditions:*

Aneurysmal vascular disease (including thoracic and abdominal aorta, intracranial, and peripheral arterial vessels) or arteriovenous malformation
History of intracerebral hemorrhage
Hypersensitivity to Esketamine, ketamine, or any of the excipients.

I have discussed this with my patient and they attest that they do not have any of the above stated conditions.

Yes, the patient indicates NO history of these conditions.

No, the patient indicates a POSITIVE history of a condition listed above.

Due to the above condition(s), this referral will be declined. Please discuss this with your patient.

Does this client have a history of psychosis?*

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Please explain the history and timeline of psychosis.*

Is the patient currently taking an oral antidepressant?*

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Medication Name & Dosage*

Additional information that would be helpful to know about this referral?

NOTE:

To fully process this referral, please upload or fax a copy of:

1.) the most recent medical note

2.) medication history and

3.) the front and back of the individual's insurance card.

Fax: 802-258-3788

Will you be faxing or uploading these documents?*

Faxing

Uploading

Documents and Insurance Card Upload

If these requested documents are not received, the referral cannot be fully processed and will result in a delay. If you are faxing these documents, please indicate so. Thank you.

Drag and drop files here or

Referring Provider Information

Referred By*

Email Address of Referring Provider*

Practice Name*

Referring Provider Telephone #*

Phone

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