Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling in the date of the request. This is essential for tracking the timely submission of the form.
3. Next, enter the number of TMS treatments requested to indicate how many sessions are being sought.
4. Fill in the patient’s name and patient ID, along with their date of birth and current home address. Accuracy in this section is critical for proper identification.
5. Provide the name and contact information of the provider who will administer the TMS treatment, including their Tax Identification Number (TIN) and phone number. Indicate if they are an in-network or out-of-network provider.
6. Complete the network exception request section if applicable, including the mailing address and phone number of the requesting provider.
7. Indicate the name of the individual at the provider's office who should be notified of the decision regarding the request.
8. Specify the requested start date for treatment, should the authorization be granted.
9. Enter the primary diagnosis. Choose one from the provided options and, if there’s a secondary diagnosis, check 'Yes' and provide details.
10. Document the clinical information by indicating when the current episode began, along with any substances used and a detailed description of the patient’s symptoms and functional impairments.
11. Assess and indicate if there are any risk of harm concerns regarding the patient by selecting 'Yes' or 'No' and providing explanations if necessary.
12. List the assessment scale used to monitor depression or OCD, along with the most current score and assessment date.
13. Detail the medication history by documenting all current and past psychopharmacologic agents the patient has tried, including classifications and dosages.
14. Identify if the patient has received evidence-based outpatient psychotherapy and, if so, complete the relevant section regarding treatment history and responses.
15. Evaluate if the patient has current or historical issues with seizures or substance use, and provide information as needed.
16. Examine if the patient has any ferromagnetic or magnetic-sensitive metals implanted, and indicate the answer.
17. Provide details about the patient’s previous experience with TMS if applicable, including date spans and assessment scores.
18. Finally, have the requesting provider sign and date the form. Ensure that the requesting provider's name is printed clearly.
19. Once all sections are completed, save the document to your computer. You can then email it to TMSBehavioralClinical@Evernorth.com or fax it to 860-687-7329.

Complete your TMS request form online today for a smooth submission process.