TMS Pre-Qualification Form
BrainHealth Solutions
Policy Holder Name
*
First Name
Last Name
Email
*
example@example.com
Insurance Company
*
Insurance Provider Phone Number
*
Member Insurance ID Number
*
Group Number
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Please upload a picture of the front of your insurance card. You can also email it to hello@brainhealth-solutions.com
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please upload a picture of the back of your insurance card. You can also email it to hello@brainhealth-solutions.com
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Date of Birth
*
-
Month
-
Day
Year
Date
List all anti-depressant medications tried in the past and currently on. Dosage not needed.
*
Please Check All That Apply Regarding How We Can Help You:
*
TMS Transcranial Magnetic Stimulation
Psychiatric Evaluation
Medication Management
Your signature below authorizes BrainHealth Solutions and the Ketamine Healing Clinic of Los Angeles, Inc. to disclose information to your insurance company to check benefits and if benefits are used, to bill the insurance company.
*
Today's Date
*
-
Month
-
Day
Year
Date
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Continue
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