External Referral -

TMS

 

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.

 
 

 

Patient Information

 
 
 
 
 
 
 
mm/dd/yyyy
 
 
Phone
 
 
 
 
 
 
 

 

Patient Demographics

 
 

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

 

Check the boxes that most accurately describe the patient's race:

 

 

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

 

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.

 
 

 
 
 
 
 

 

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

 
 

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.

Drop your files here
 

 
 
 
Phone