Referral JOT Forms

TMS EXTERNAL REFERRAL FORM

Outpatient Clinic
IF THE PATIENT IS EXPERIENCING A MEDICAL OR PSYCHIATRIC EMERGENCY, DO NOT FILL OUT THIS FORM. INSTEAD CALL 911, GO TO THE NEAREST ED, OR CALL 988 FOR ADDITIONAL CRISIS RESOURCES.
Name*

Legal First NameLegal Last Name
DOB*
Previous Names Used
Preferred Name
Social Security #
Guardian Conservator If Applicable
Mailing Address*
Street Address if different
City*
State*
Zip Code*
*Phone #*
Email
example@example.com
Preferred Method of Contact*
May we leave a message with patient information on the preferred phone # above?*

YesNo
*Check the boxes that most accurately describe ethnic origin:*

Yes, Mexican, Mexican American, Chicano/aNo, Not HispanicYes, Puerto RicanYes, Other Hispanic OriginRefused
What is the primary language?*

American Sign LanguageArabicChineseEnglishFrenchGermanHindi/Indie LanguagesItalianRussianSpanishVietnameseOther
Check the boxes that most accurately describe race:*

American Indian or Alaskan NativeAsian IndianBlack or African AmericanChineseFilipinoGuamanian or ChamorroJapaneseKoreanNative HawaiianOther AsianOther Pacific IslanderSamoanVietnameseWhiteRefuse
INSURANCE INFORMATION
Primary Insurance*
Primary Insured Party Name*
DOB*
Relationship to Patient*
Policy*
Group*
Effective Date*

MonthDayYear
Date
Expiration Date*

MonthDayYear
Date
Secondary Insurance
Primary Insured Party Name
DOB
Relationship to Patient
Policy
Group
Effective Date

MonthDayYear
Date
Expiration Date

MonthDayYear
Date
CRITERIA AND HISTORY

(For appropriateness and authorization)
Please enter any information you have about specific medication trial including dates, dosages, and responses that may be relevant to obtaining authorization for TMS treatment:*
Diagnosis (this is relevant to this referral). Note: Medicare and most private insurers restrict TMS treatment to diagnoses of Major Depressive Disorder, severe. If bipolar disorder is the current diagnosis, please explain the depressive presentation in this referral.*
Does client meet criteria for treatment resistant depression as defined by CMS? (four medication trials in two categories):*

YesNo
Evidence-based psychotherapy for depression:*

Dialectical Behavioral Therapy (DBT)Interpersonal PsychotherapyCognitive Behavioral PsychotherapyProblem-Solving TherapyBrief Psychodynamic PsychotherapyOther
Please describe any history or hospitalization and how recent*
Has the patient ever had ECT?*

YesNo
Additional information that would be helpful to know about this referral?*
REFERRING PROVIDER INFORMATION
Referred by*
Practice Name*
Email address of referring provider*
example@example.com
Phone Number*
Please enter a valid phone number.
Date*

MonthDayYear
Date
To fully process this referral, please fax (802)258-3788 or email outpatient@brattlebororetreat.org a copy of:

1) Most recent medical note

2) Medication history

3) Front and back of the individual's insurance card.

Should there be any required information missing, a Practice Management Team member will reach out within 24 business hours to gather the information prior to being able to process the referral.
Should be Empty:

CRITERIA AND HISTORY