Appointment Request / Insurance Check

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Today's Date
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This appointment is for:* This field is required.
Free New Client Initial Consult With Dr. Hashemian
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Who Is This appointment for?:* This field is required.
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Patient's Date of Birth* This field is required.
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Patient's Name* This field is required.
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Patient's Gender
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This person is:* This field is required.
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What is Your Name?* This field is required.
Your First Name:
Your Last Name:
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What is Your Email?* This field is required.
example@example.com
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Your Phone Number Which Can Receive Texts:* This field is required.
Best number to reach you during business hours (we will not contact you other than for appointment reminders or to answer your questions):
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Zip Code:
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In which of our offices would you like to receive our services?* This field is required.Some services are offered at home, but at least one office visit is required.
Modesto
San Jose
San Ramon
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Can You Manage the drive to our office?Here are the Number of office visits required

Insurance Covered TMS

36 Daily Visits ( Monday-Friday). Treatment Is Under 30 Minutes

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Self-Paid TMS & Accelerated TMS:

5-20 Visits Total, Daily or 2-5 Times a Week

2 Treatments Each Hour, Up to 10 Treatments in 9 hours

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Neurofeedback & Auditory Training:

Auditory Training and Neurofeedback can be done at home under our supervision

2-6 Visits Total, Every 2-6 Weeks =================================================================================================

qEEG Brain Imaging and Cognitive Assessments

These Assessments are completed in one appointment, approximately 1-3 hours long, depending on the assessment and age of the patient. Results are reviewed via Zoom 2-3 days post appointment

1-2 Visits Total
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Your ZIP code and press ENTER:* This field is required.Let's find out the distance and your travel time.
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City-Distance
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Your ZIP code and press ENTER:* This field is required.Let's find out the distance and your travel time.
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Your ZIP code and press ENTER::* This field is required.Let's find out the distance and your travel time.
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Seems you are too far away to qualify for a free appointment. We do offer a 25-minute paid consultation for $95, which will be credited towards any services. Feel welcome to call us for more information at 925-873-1100
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Would you like to be added to our mailing list?* This field is required.
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Thank you for your interest

Please

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Age (Don't Show)
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Patient Age
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I am interested in finding out more about:* This field is required.
I am not sure
Functional qEEG Brain Mapping [We Do Not Accept Insurance For This Service]
TMS (Insurance Might Cover for Depression, 18+ with 2 or more antidepressants)
Neurofeedback [We Do Not Accept Insurance For This Service]
Auditory Training [We Do Not Accept Insurance For This Service]
tDCS [We Do Not Accept Insurance For This Service]
Full Diagnostic Evaluation [We Do Not Accept Insurance For This Service]
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My challenges are:* This field is required.If not listed here, you can add it to the comment field at the end of this form.
Depression
Bipolar
Anxiety
OCD
ADHD
Autism
Asperger’s
Auditory Processing Disorder
Dyslexia
Learning Disorder
Developmental Delays
Addiction
Brain Injury / Brain Fog
Postconcussive Syndrome (PCS)
Chronic Pain
Insomnia- Sleep-Related Issues
Memory
PTSD
Tinnitus
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Have you ever taken any Antidepressants (even for few days) ?* This field is required.This might help with possible Insurance approval
Yes
No
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In The Past 2 Years, Have You Taken Any of These:* This field is required.To Qualify For Insurance Coverage, You Must Have Taken 2 or More of these; Proof Is Not Required. If not listed here, you can add it to the comment field at the end of this form.
Abilify / Aripiprazole
Anafranil / Clomipramine
Ascendin / Amoxapine
Auvelity / Dextromethorphan + Bupropion
Celexa / Citalopram
Cymbalta / Duloxetine
Desyrel / Trazodone
Emsam / Selegiline
Effexor / Venlafaxine
Elavil / Amitriptyline
Fetzima / Levomilnacipran
Geodon / Ziprasidone
Lexapro / Escitalopram
Luvox / Fluvoxamine
Ludiomil / Maprotiline
Nardil /Phenelzine
Norpramin / Desipramine
Pamelor / Nortriptyline
Parnate / Tranylcypromine
Paxil / Paroxetine
Pristiq / Desvenlafaxine
Prozac / Fluoxetine
Remeron / Mirtazapine
Rexulti / Brexpiprazole
Risperdal / Risperidone
Savella / Milnacipran
Serzone / Nefazodone
Seroquel / Quetiapine
Spravato / Esketamine
Surmontil / Trimipramine
Tofranil / Imipramine
Trintellix / Vortioxetine
Viibryd / Vilazodone
Vivactil / Protriptyline
Wellbutrin / Bupropion
Zoloft / Sertraline
Zulresso / Brexanolone
Zyprexa / Olanzapine
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Calculation of how many antidepressants taken
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We Are In-Network For TMS Services With:* This field is required.If you do not see your insurance plan, please text or call us at 925-837-1100
Aetna (In-Network)
Anthem (In-Network)
Blue Cross(In-Network)
Blue Shield (In-Network)
Blue Shield+Blue Cross (In-Network)
Carelon (In-Network)
Cigna - Evernorth (In-Network)
Evernorth (In-Network)
Healthnet (In-Network)
Humana (In-Network)
Modesto Kaiser - Restricted to Modesto area residents only
MHN (In-Network)
Magellan (In-Network)
Medical Lien
Meritain Health
San Joaquin County Health Plan BHRS
Stanislaus County BHRS
Medicare
Optum (In-Network)
Tri-Care (In-Network)
Tri-West (In-Network)
UMR
United (In-Network)
Other- Uninsured or Not Listed
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Check insurance coverage for these services?* This field is required.
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No
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Would you like to be added to our mailing list?* This field is required.
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Thank you for your interest. Click here to clear your data.
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Kaiser coverage is limited to Modesto area Only. Do you within with area?* This field is required.
Yes
No
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Sorry, We Do Not Accept Insurance for the services you listed

We only accept insurance for treatment of major depression using TMS.

Most plans require:

- Diagnosed with Major Depression

- Tried At Least 2 Antidepressants

- Talk Therapy in the Past 6 Months

- 18 or Older (Soon to be 15+)

We are in-network with all commercial insurance plans in California but only for TMS to treat depression.

We will take care of prior authorization and no referral is needed from your doctors.
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Would you like to proceed on a self-pay basis? We will provide a detailed, itemized receipt. HSA & Credit Cards accepted* This field is required.
Yes
No
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Would you like to be added to our mailing list?* This field is required.
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Thank you for your interest. Click here to clear your data.
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Good news! Your plan may cover depression treatment using TMS. Would you like to schedule your free consultation appointment now?* This field is required.
Yes
No
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Would you like to be added to our mailing list?* This field is required.
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Thank you for your interest. Click here to clear your data.
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TMS to treat depression in adults Who have failed to respond to medications, is the only service we accept Insurance for.

Otherwise, all services are self-paid.

Our Fees Start at:

qEEG Brain Imaging $2,995

Treatments: $4,000-$12,000

Please Review Our Fees Before Booking
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After reviewing the cost of our services, would you still like to proceed?* This field is required.
Yes
No
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Would you like to be added to our mailing list?* This field is required.
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Thank you for your interest. Click here to clear your data.
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How did you hear about us?* This field is required.
Doctor Referral
Google/Search Engine
Family/Friend
Facebook/Instagram/Youtube or other Social Media
Kaiser
County
Past Patient
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Thank you for your interest. Check back soon, as conditions do change quickly. Please press SUBMIT and you will be added to our mailing list.
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List any medications, insurance companies not listed, or your comments:Please list medications, insurance company, or condition that was not listed on this form previously .
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