Get Outpatient Ect Referr Nd Order - Sheppard Pratt - Sheppardpratt

Filling out the Outpatient ECT Referral and Order form is a crucial step in the process of referring a person for electroconvulsive therapy. This guide provides clear, step-by-step instructions to ensure that you can complete this form effectively and accurately.

Follow the steps to complete the Outpatient ECT Referral and Order form online.

1. Click 'Get Form' button to obtain the form and open it in the document editor.
2. Enter the patient's name in the designated field at the top of the form.
3. Provide the date of birth for the patient next to the name entry.
4. Input the name of the insurance company the patient is covered by.
5. Fill in the policy number associated with the insurance coverage.
6. Include the appropriate DSM 5 code relevant to the patient's diagnosis.
7. Detail the rationale for ECT and any past medication trials the patient has undergone.
8. List the current medications the patient is taking along with their dosages.
9. Describe the symptoms the patient is experiencing.
10. Indicate the duration of the current symptoms in the relevant section.
11. If applicable, note any suicidal ideation that the patient has expressed.
12. Document the patient's psychiatric history, including past suicidal history.
13. Provide information regarding any chemical dependency history.
14. Mention any inpatient or outpatient psychiatric treatment the patient has received.
15. In the ECT Order section, specify whether the proposed treatment is bilateral or unilateral.
16. Indicate the frequency and total number of treatments proposed (e.g., 3x/week for 12 treatments).
17. The referring psychiatrist should sign and date the form in the designated areas.
18. Print the referring psychiatrist's name clearly under the signature.
19. Include the phone number and fax number for the referring psychiatrist.
20. The ECT psychiatrist will review the referral information, sign, and date the form.
21. Include the printed name of the ECT psychiatrist beneath their signature.
22. Finally, fax the completed form to the ECT/Medical Department at the provided fax number.
23. If you have further questions, contact the specified phone number for assistance.

Complete the Outpatient ECT Referral and Order form online to ensure prompt processing.