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Ordering Provider
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Providers:
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Referring Provider:
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Primary Insurance Name:
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Behavioral Health Insurance Name:
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Primary Insurance ID:
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Behavioral Health Insurance ID:
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Primary Diagnosis Code For TMS:
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Primary Diagnosis Code for TMS:
• • •
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Other:
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Rating Scales used prior, during, and after treatment:
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Rating Scales
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Evidence-Based Psychotherapy:
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Has the patient had evidence-based psychotherapy known to be effective in the treatment of Major Depressive Disorder of an adequate frequency and duration without significant improvement in depressive symptoms as documented by standardized rating scales?
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Has the patient had evidence based psychotherapy that was found to be effective in the treatment of Major Depression Disorder?
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Contraindications:
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Does the patient have any contraindications for TMS?
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Meets Medical Necessity:
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Tried and failed two antidepressants from different classes?
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See TMS Screening Questionnaire
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