Clinician Referral Form
Transcranial Magnetic Stimulation
Patient Contact Info
Patient Name
*
First Name
Last Name
Date of Birth
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Month
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Day
Year
DOB
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
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District of Columbia
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Tennessee
Texas
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State
Zip Code
Insurance Carrier
Please Select
VIRGINIA MEDICAID
AETNA BETTER HEALTH (MEDICAID)
HEALTHKEEPERS PLUS (MEDICAID)
UHC COMMUNITY PLAN (MEDICAID)
OPTIMA/SENTARA (MEDICAID)
MOLINA (MEDICAID)
HUMANA MEDICARE HMO PLAN
ANTHEM/ HK / BCBS / BLUE CROSS PLANS
BLUE CROSS FEDERAL (prefix “R”)
SENTARA COMMERCIAL (NON MEDICAID)
AETNA (COMMERCIAL PLANS)
TRICARE
MEDICARE
UNITED HEALTHCARE (COMMERCIAL PLANS)
Member ID #
Insurance Card front
Insurance Card back
Referring Clinician Info
Provider Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Referring Organization Name
Reason for Referral
MDD, Treatment-Resistant Depression
Obsessive-Compulsive Disorder (OCD)
Other
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BY SUBMITTING THIS FORM, I AM PROVIDING EXPRESS WRITTEN CONSENT FOR SEVA PSYCHIATRY TO CONTACT ME AT THE PHONE NUMBER I PROVIDED, INCLUDING THROUGH TEXT MESSAGES AND PHONE CALLS, REGARDING SERVICES, APPOINTMENTS, OR OTHER RELEVANT INFORMATION.
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