NAPA | North Alabama Psychaitric Associates



Transcranial Magnetic Stimulation (TMS) Brief Clinician Referral Form(To be filled out by referring provider)TMS is a depression treatment that can improve response in patients for which current medication therapies and psychotherapies for major depression have not provided satisfactory results, or persons who have experienced negative side- effects from medications.Patient Name: __________________________________ Date of Birth: __________________ Address: ____________________________________________________________________ Patients Phone#: __________________________ Cell Phone# _________________________Insurance Carrier: _________________________Contract Policy #: _____________________ Contract Group# ____________________Insurance Phone#: ___________________________Referring Dr._______________________ Office Contact: _____________________________Office Number: __________________________Fax Number: __________________________Discussed TMS as a treatment option with patient: □Yes or □NoDoes patient have a diagnosis code of:□F32.9 □F32.0 □F32.1 □F32.2 □F32.3 □F32.4 □F32.5 □F32.8 □F33.9 □F33.0 □F33.1 □F33.2 □F33.3 □F33.41 □F33.42 □Other: _____________Has patient tried at least four (4) antidepressant medications? □Yes or □No: if yes (Please Fax Medication List with this referral form)Has patient tried psychotherapy? □Yes or □No if yes Where and When? ______________________________________________________________________________Any non-removable metal in or around the patient’s head? □Yes or □NoDoes the patient have a pacemaker? □ Yes or □No Has patent had prior ECT or TMS? □ Yes or □No if yes:Dates: ___________________________ Where: _____________________________________History of Seizures? □Yes or □No Family History of Seizures? ____________________Please Fax to 256-322-4987 or Mail to:Attention: TMS CoordinatorNorth Alabama Psychiatric Associates PC953 Jeff Rd NWHuntsville, AL. 35806Fax # (256) 322- 6272 Phone# (256) 322-4987 ................
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