Get Transcranial Magnetic Stimulation Request - Anthem Blue Cross

Filling out the Transcranial Magnetic Stimulation Request form for Anthem Blue Cross can be a straightforward process if you follow the provided steps. This guide is designed to give you clear instructions on how to complete the form accurately and efficiently.

Follow the steps to complete the TMS request form online.

1. Press the ‘Get Form’ button to access the Transcranial Magnetic Stimulation Request form and open it in your document editor.
2. Begin by entering the member's full name in the 'Member Name' field. Ensure the name matches the one on their insurance policy.
3. Provide the member's ID number in the 'ID #' section, which is critical for identification purposes.
4. Fill in the member's date of birth accurately in the 'Member Date of Birth' field, as it is necessary for age verification and eligibility assessment.
5. Enter the current age of the member in the designated field to ensure compliance with any age-related requirements.
6. Complete the member's address details in the 'Member Address' section to facilitate communication.
7. Provide a contact number for the member in the 'Member Contact Number' field for follow-up questions or clarifications.
8. Under 'Requesting TMS Office Information,' include the physician's name in the indicated space, as this identifies the treating clinician.
9. Fill in the physician's phone number for easy contact concerning the treatment request.
10. Include the office manager's name and their phone number to facilitate administrative correspondence.
11. Provide the office address of the requesting TMS office to ensure proper routing of the request.
12. If applicable, provide information for outpatient practitioners, including psychiatrist and therapist names and their contact numbers.
13. Check all relevant boxes regarding the member's eligibility and treatment history. This includes confirming the diagnosis and treatment trials.
14. If the member has failed to respond to previous treatments, document the required medication trials, including the medication name, dose, and outcomes.
15. Indicate if the proposed TMS treatment is consistent with FDA guidelines by confirming the stimulation parameters.
16. Conclude by signing the form, ensuring all information is verified as accurate and complete before submission.
17. Once completed, save the form. You can also download, print, or share it as needed before faxing it to the provided number.

Complete the Transcranial Magnetic Stimulation Request form online today to ensure a timely review of your request.