Get Evernorth 924445 2021

This guide is designed to assist users in completing the Evernorth 924445 online request form for Transcranial Magnetic Stimulation (TMS). By following these clear and structured steps, you will ensure that the form is filled out accurately and comprehensively.

Follow the steps to complete the Evernorth 924445 request form.

1. Click the ‘Get Form’ button to access the Evernorth 924445 form and open it in the online editor.
2. Enter the date of request in the specified field. This marks the official date of your submission.
3. Indicate whether this is an initial or concurrent request by selecting the appropriate option.
4. Fill in the customer’s name, ID, and date of birth accurately to identify the individual receiving treatment.
5. Provide the name and contact details of the provider who will administer the TMS treatment, including the TIN and phone number.
6. Specify if the provider is in-network or out-of-network by checking the applicable box.
7. Complete the service address where the treatment will take place, ensuring that all information is clear and legible.
8. If applicable, indicate if the requesting provider is the same as the treatment provider and provide their information.
9. Fill in the name of the person at the provider's office who should be notified of the decision regarding the request.
10. Indicate the requested start date for treatment, should the authorization be granted.
11. Specify the primary diagnosis using the provided options, including any relevant ICD-10 codes.
12. Provide detailed clinical information about the customer's depression episode, symptoms, and any substance use.
13. Assess the risk of harm, detailing any suicidal or homicidal ideations clearly if they exist.
14. Document the assessment scale used to monitor depression, including scores and dates of the latest assessments.
15. Record the medication history, listing all current and past psychiatric medications with dosages and responses.
16. Indicate any previous outpatient psychotherapy history and results.
17. Specify any current or historical health issues, such as seizures or substance use, and their management.
18. Address questions related to ferromagnetic materials and previous TMS treatments, including associated scores.
19. Provide your signature and date to authenticate the request, followed by printing or saving the completed form.
20. Once completed, save the form to your computer and email it to TMSBehavioralClinical@Evernorth.com or fax it to 860-687-7329.

Take a few moments to complete the Evernorth 924445 form online and ensure your request is submitted correctly.