External Referral

Instructions:

Please fill out any information that is easily/readily known about your patient; we understand that information about specific dates or years and medication dosages may not be available or obtainable. We ask for this information to help in the evaluation and insurance authorization process.

Date of referral*

Patient Information

Patient name*

Patient's Pronouns

Patient's Address*

Patient's Email

Patient Date of Birth*

Patient's Social Security #

Patient Phone*

Phone

Patient Health Insurance Carrier*

Patient Insurance ID #*

Patient Secondary Insurance Details

Patient Demographics

Ethnic Origin*

Check the boxes that most accurately describe the patient's ethnic origin:

Criteria and History (for appropriateness and authorization)

Please enter any information you have about specific medication trials including dates, dosages, and responses that may be relevant to obtaining authorization for TMS treatment

Patient's diagnosis (that is relevant to this referral)*

Note: Medicare and most private insurers restrict TMS treatment to diagnoses of Major Depressive Disorder, severe. If bipolar disorder is the current diagnosis, please explain the depressive presentation in this referral.

Does client meet criteria for treatment resistant depression as defined by CMS? (four medication trials in two categories)*

Select or enter value

Evidence-based psychotherapy for depression

Has the patient ever had ECT?

Select or enter value

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

File Upload

If the 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/Agency Name*

Your email address*

Best phone number to contact you*

Phone

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