Benefits Request

Benefits Request

Carrier Investigation for TMS Services
Terms for Reference: Benefits Authorization
Pt/Member Name:*

First NameLast Name
Pt/Member DOB:*

MonthDayYear
Insurance Carrier:*
Pt/Member ID:*
Insurance Policy ID #
Has Pt/Member Been Prescribed Antidepressants?*

YesNo
Policyholder Name (If Diff. Than Pt/Member):
Insurance Policy ID #
Policyholder DOB

MonthDayYear
*ID & Ins. Card Images Required Unless Already Submitted*
FRONT of Pt/Member License or ID

Browse Files

Cancelof
FRONT of Pt/Member Ins. Card

Browse Files

Cancelof
BACK of Pt/Member Ins. Card

Browse Files

Cancelof
Additional Carrier Info:
Please include any additional info about ins. carrier/policy that might be helpful.
Submitting form allows HH Personnel to retrieve

coverage/benefits details from Patient/Member's carrier.

All information shared is handled confidentially

& according to standard privacy policy/practices.
Should be Empty: