TMS Referral Form • Cutting Edge Health

First Name *

Last Name *

Date of birth *

Phone

Email Address *

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Primary Insurance Carrier Name: *

Member ID # / Subscriber ID # *

Group Number

Does the patient have a secondary / supplement insurance plan? *NoYes

Secondary Insurance Carrier Name:

Member ID # / Subscriber ID #

Group Number

Provider Full Name (First, Last, Credential) *

Provider NPI:

Clinic/Practice/Institution Name: *

Provider Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Clinic Phone

Clinic Fax

Name of Contact Person within your office:

Primary Indication for TMS TreatmentF33.2 Major Depressive Disorder, recurrent severe w/o psychosisF42.2 OCD, Mixed obsessional thoughts and actsF42.9 OCD, unspecifiedOther, please list

List ICD-10 code for Primary Indication of Treatment

Patient is 18 years old or older: *YesNo

Patient has received TMS before: *YesNo

Patient has failed at least two antidepressant medications (lack of clinically significant response to trials or inability to tolerate with distinct side effects) from two different agent classes. *YesNo

Provide details on failed antidepressant/adjunct medication trials (Name, max doe, time-frame taken, reason fo stopping)

History of epilepsy or history of seizure or presence of other neurologic disease that may lower seizure threshold *NoYes(eg, cerebrovascular accident, severe repetitive head trauma, increased intracranial pressure)

Implanted metallic hardware or implanted magnetic-sensitive medical device *NoYes(eg, cochlear implant, deep brain stimulator, vagus nerve stimulator, cardioverter-defibrillator, pacemaker, metal aneurysm clips or coils, at a distance within the electromagnetic field of the discharging coil (eg, less than or equal to 30 cm to the discharging coil)

Acute or chronic psychotic symptoms or disorder *NoYes(eg, schizophrenia, schizophreniform or schizoaffective disorder)

Patient has participated in psychotherapy *No, neverYes, currentlyYes, previously, but no longer continuing

Additional information that may be helpful to know about your patient:

Referral for TMS Services