Get Please Complete This Form In Its Entirety And Fax To 860-687-7329

Completing the form for Repetitive Transcranial Magnetic Stimulation is a critical step in initiating treatment. This guide will walk you through the process step-by-step to ensure you fill out the Please Complete This Form In Its Entirety And Fax To 860-687-7329 accurately and efficiently.

Follow the steps to complete the form correctly.

1. Press the ‘Get Form’ button to acquire the document you need. This will open the form in the designated editor for you to begin filling it out.
2. Start by indicating the network status of the patient by selecting either 'In Network' or 'Out of Network'. This ensures the correct billing is applied for the requested services.
3. Enter the patient's details in the corresponding fields. This includes the member name, date of birth, health plan, policy number, and gender.
4. Fill in the date and time of the request along with the treating clinician or facility details. If a different clinician is making the request, confirm whether they have notified the treating clinician.
5. Complete the initial treatment section by providing details on the confirmed diagnosis of major depressive disorder. Select the appropriate diagnosis code and pre-treatment rating scales.
6. Indicate any resistance to treatment or inability to tolerate specific medications by checking the applicable boxes. This section is vital for justifying the need for TMS treatment.
7. List any potential contraindications the patient may have, as well as their current and past medical history that is relevant to the treatment being requested.
8. For retreatment scenarios, confirm whether the patient meets the necessary guidelines by checking the boxes. Provide any post-treatment rating scale scores.
9. Select the FDA-approved TMS device type that corresponds to the type of treatment being requested. Ensure all relevant options are checked.
10. Once all sections are complete, make sure to review the document for accuracy. You can save your changes, download a copy, or print the form for faxing.

Complete your documents confidently online and ensure they are sent to the correct fax number.