Get Tms Request Form - Anthem

The TMS Request Form - Anthem is a crucial document for initiating transcranial magnetic stimulation treatments. Completing this form accurately ensures a timely review and response from the appropriate medical team.

Follow the steps to successfully complete the TMS Request Form - Anthem.

1. Click 'Get Form' button to access the form and open it in the provided document interface.
2. Begin by filling in the member's name and date of birth in the designated fields. Ensure this information is accurate to avoid delays.
3. Provide the member's ID number and current age. Double-check for correctness.
4. Input the name and phone number of the requesting physician, ensuring all contact details are filled correctly.
5. List all current diagnoses for the member. Use clear and precise language to describe each condition.
6. Detail the current episode of depression by documenting all medication trials. Include specific dates, maximum dosages, and the duration of each trial. Note any outcomes and side effects experienced.
7. If applicable, specify prior electroconvulsive therapy (ECT) trials, including dates and number of treatments administered.
8. Document psychotherapy trials and their outcomes. Indicate the therapeutic model used, the focus of therapy, date ranges, and frequency or number of sessions held.
9. Indicate whether the patient has previously received TMS treatment by marking 'Yes' or 'No.' If 'Yes,' provide detailed information on dates, courses, devices used, stimulus parameters, session numbers, and clinical responses.
10. Describe the proposed treatment, including the administration parameters of TMS, the number of requested sessions, and anticipated start date.
11. List the standardized instruments that will be utilized to measure the response to TMS.
12. Confirm that an FDA approved device will be utilized for the treatment.
13. Affirm that there are no contraindications related to the TMS treatment that apply to the member, providing any relevant medical details.
14. Finish by signing the form, printing your name, and entering the date of completion. Ensure all information provided is accurate and reflects the member's clinical assessment.
15. If needed, utilize additional pages for more information before finalizing your submission. Once complete, you can save changes, download, print, or share the form.

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