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TMS Authorization Request Form

IMPORTANT NOTE:

  • TMS approvals are subject to adherence with the following coverage guidelines. Please review prior to requesting services.

  • Authorization is contingent upon the member’s eligibility, terms of benefit plan, and state regulations

  • Please confirm member eligibility and coverage prior to completing this request

  • Only complete submissions will be considered as an official request for services

 

TMS Guidelines and Guidance

  • TMS Supervision must be consistent with the Optum Behavioral Health Clinical Policies: Transcranial Magnetic Stimulation

  • The person monitoring the patient must be trained in CPR and seizure identification/management

PART I OF II

Povide is directly supervising technician by:

Part 1 Complete. Proceed to Part 2.

PART II

Has the member historically or currently been diagnosed with any of the following
List all medication trials in the Current and Lifetime Episodes of Major Depressive Disorder.
Trials of evidence-based psychotherapy known to be effective in the treatment of MDD [at least one required]
Medical Concerns
Are you interested in TMS or SAINT Protocol?

Thanks for submitting!

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