Get Evernorth 924445 2020

This guide provides comprehensive instructions for completing the Evernorth 924445 request form online. Whether you are a clinician or a healthcare professional, this step-by-step approach will help ensure all necessary information is accurately filled out.

Follow the steps to effectively complete the Evernorth 924445 form.

1. Click 'Get Form' button to access the Evernorth 924445 request form and open it in your chosen editor.
2. Fill in the 'Date of Request' and indicate whether this is an initial or concurrent request. Provide the 'Customer Name' and 'Customer ID' along with their 'Date of Birth'.
3. Enter the name and TIN of the provider who will administer the TMS treatment, as well as their phone number, and specify if they are an in-network or out-of-network provider.
4. Fill out the service address details, including the apartment/ste number, state, zip code, and city. Indicate if the requesting provider is the same as the treatment provider.
5. Complete the 'Name of person at provider's office to notify' section, including their phone number.
6. Provide the 'Requested start date for treatment' if authorization is granted, and specify the primary diagnosis with corresponding ICD-10 codes.
7. In the 'Clinical Information' section, document the start date of the current episode of depression, substance use details, description of symptoms, and any relevant functional impairments.
8. Answer if there are concerns regarding risk of harm, including suicidal ideation, and provide explanations where necessary.
9. Detail the assessment scale used to monitor depression, including the type, score, and date of the most recent assessment.
10. Document the medication history, listing all psychopharmacologic agents tried by the customer, with corresponding dosages and response/side effects.
11. Indicate if the customer has received evidence-based outpatient (OP) psychotherapy without significant improvement, providing relevant details.
12. Answer medical history questions regarding seizures, substance use, and ferromagnetic material.
13. Provide information if the customer has a history of previous good response to TMS, including relevant treatment dates and assessment scores.
14. Finally, the requesting provider should complete the signature section, including their name and fax number.
15. Once all sections are thoroughly filled, save the form to your computer. You can then email it to TMSBehavioralClinical@Cigna.com or fax it to 860-687-7329.

Complete your Evernorth 924445 request form online for a seamless experience.