Insurance Verification Form

Insurance Verification Form

TMS Screening and Insurance Form

Rows	Yes	No
Are you a new TeleMind patient?
History of Psychotherapy
Have you had TMS Before?
History of Seizure?
I have no magnetic sensitive metals in my head such as: Stents, Aneurysm clips or coils, Implanted Stimulators or Electrodes, Bullet Fragments, Ferromagnetic eye or ear implants, or other metal devices implanted in my head

Notes
Please Write Details for any Yes answers
Past Psychiatric Diagnoses:*
Current Doctor or Referral Source:*
Type N/A if none

Psychiatric Medication History

Rows	Name	Dose	Dates Taken	Side Effects
Medication
Medication
Medication
Medication
Medication
Medication
Medication
Medication

Insurance Verification Form
Name*

First NameLast Name
If You are a current TeleMind Patient with no recent insurance changes you can put NA in the below fields and submit.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Format: (000) 000-0000.
Email*
example@example.com
Date of Birth*

MonthDayYear
Gender*

Insurance Information
If You are a current TeleMind Patient with no recent insurance changes you can put NA in the below fields and submit.
Primary Insurance Co*
Group No*
Policy No*
Subscriber's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Subscriber's Relationship to Patient*
Secondary Insurance Co
Policy No
Group No
Subscriber's Name

First NameLast Name
Subscriber's Relationship to Patient
Notes
File Upload

Cancelof
Should be Empty: