Specialty Medication Clinic -
External Referral

Date of referral

Patient Information

Patient's Legal Name

Patient's Preferred 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

Subscriber's Name

Subscriber's Relationship

Self

Spouse

Parent

Secondary Insurance Details

Patient Demographics

Presenting Problem(s)

Diagnosis

Medication being requested

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

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.

Does this client have a history of psychosis?

Is the patient currently taking an oral antidepressant?

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.

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Referring Provider Information

Referred By

Email Address of Referring Provider

Practice Name

Referring Provider Telephone #

Phone

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Specialty Medication Clinic - External Referral

Patient Information

Patient Demographics

Presenting Problem(s)

NOTE:

Referring Provider Information

Specialty Medication Clinic -
External Referral