Get Evernorth 924445 2022

Filling out the Evernorth 924445 form is an essential step for requesting Transcranial Magnetic Stimulation (TMS) treatments. This guide will walk you through each section of the form, ensuring you provide all necessary information clearly and accurately.

Follow the steps to complete the Evernorth 924445 form online.

1. Click ‘Get Form’ button to obtain the document and open it in the editor.
2. Provide the date of the request. Ensure you enter the correct date to avoid any processing delays.
3. Fill in the customer’s name and customer ID. This information must be accurate for proper identification.
4. Indicate the number of TMS treatments requested and the customer’s date of birth.
5. Enter the current home address of the customer, including the apartment or suite number, state, zip code, and city.
6. Identify the provider who will administer the TMS treatment, including their TIN and phone number. Specify if the provider is in-network or out-of-network.
7. If the requesting provider is the same as the treatment provider, indicate this; otherwise, provide the name, TIN, and mailing address of the requesting provider.
8. List the name and phone number of the person at the provider’s office to notify about the decision.
9. Enter the requested start date for treatment, assuming authorization is granted.
10. Select the primary diagnosis from the provided options. Include any secondary diagnosis if applicable.
11. Provide clinical information, including the start date of the current episode of depression, any substances used, last substance use date, and a description of the symptoms and functional impairments.
12. Indicate any risks of harm concerns, such as suicidal ideation, and provide explanations when necessary.
13. Record the assessment scale used to monitor depression or OCD, along with the score and date of the most current assessment.
14. Detail medication history, documenting all current and past psychopharmacologic agents, dosages, and dates.
15. State the current or past history of outpatient psychotherapy. If applicable, include details about facility/provider names and treatment dates.
16. Mention any history of seizures or substance use, including the current management approach if applicable.
17. Confirm whether the customer has any magnetic-sensitive metals implanted and if they have a history of good response to TMS.
18. Final step: After completing the form, save it to your computer. You can then email it to TMSBehavioralClinical@Evernorth.com or fax it to 860-687-7329.

Complete your Evernorth 924445 form online today to ensure your request is processed smoothly.