FACTMS California Access to Lessening Maternal Depression via TMS (CALM-TMS)

FACTMS California Access to Lessening Maternal Depression via TMS (CALM-TMS)
Section 1. Clinic Information
Clinic Name
Clinic Address
City
State
Zip Code
Primary Contact Name

First NameLast Name
Primary Contact Title
Primary Contact Email
example@example.com
Primary Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Treating Clinician Name

First NameLast Name
Treating Clinician Credentials
Treating Clinician Email
example@example.com
Treating Clinician Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
CTMSS Membership

Section 8. Clinic Attestation
I certify that: The information contained in this application is true and accurate. Clinical responsibility remains solely with the treating clinic and clinician. The clinic will comply with all program reporting requirements. The clinic will maintain appropriate documentation supporting reimbursement requests. The clinic acknowledges that reimbursement is contingent upon submission of required data (preganancy outcome information may not be feasible) and documentation and completion of treatment. Partial reimbursement may be provided if treatment is discontinued due to delivery, medical complications, or clinical judgment, provided baseline de-identified data is submitted.
I certify that
Authorized Representative

First NameLast Name
Title
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Section 1. Clinic Information