Appointment Request / Insurance Check

Today's Date

Date

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Free New Client Initial Consult

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Myself

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Patient's Date of Birth* This field is required.

Date

Patient's Name* This field is required.

First Name

Last Name

Patient's Gender

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Female

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What is Your Name?* This field is required.

Your First Name:

Your Last Name:

What is Your Email?* This field is required.

example@example.com

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):

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

How Far Are We?

Neurofeedback, Auditory Integration Training, and Cognitive Re-Training can be done from home

TMS is In-Office

Your ZIP code and press ENTER:* This field is required.Let's find out the distance and your travel time.

Your ZIP code and press ENTER::* This field is required.Let's find out the distance and your travel time.

I'm sorry, but we are too far away to offer you a free appointment. We do offer a 25-minute paid consultation for $195, which will be credited towards any services you use, you can also call us at 925-871100

Yes

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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]

My challenges are:* This field is required.

Depression

Bipolar

Anxiety

OCD

ADHD [We Do Not Accept Insurance For This Service]

Autism [We Do Not Accept Insurance For This Service]

Asperger’s [We Do Not Accept Insurance For This Service]

Auditory Processing Disorder [We Do Not Accept Insurance For This Service]

Dyslexia [We Do Not Accept Insurance For This Service]

Learning Disorder [We Do Not Accept Insurance For This Service]

Developmental Delays [We Do Not Accept Insurance For This Service]

Addiction [We Do Not Accept Insurance For This Service]

Brain Injury / Brain Fog [We Do Not Accept Insurance For This Service]

Postconcussive Syndrome (PCS) [We Do Not Accept Insurance For This Service]

Chronic Pain [We Do Not Accept Insurance For This Service]

Insomnia- Sleep-Related Issues [We Do Not Accept Insurance For This Service]

Memory [We Do Not Accept Insurance For This Service]

PTSD [We Do Not Accept Insurance For This Service]

Tinnitus [We Do Not Accept Insurance For This Service]

Other

Have you ever taken any Antidepressants (even for few days) ?* This field is required.This might help with possible Insurance approval

Yes

TMS Insurance Coverage Requires Trial of 2 or More of These, Even if for a Week (Proof Is Not Required)* This field is required.Even if for one day

Auvelity

Celexa/Citalopram

Cymbalta/Duloxetine

Effexor/Venlafaxine

Elavil/Amitriptyline

Fetzima

Lexapro/Escitalopram

Luvox/Fluvoxamine

Nardil /Phenelzine

Norpramin/Desipramine

Pamelor/Nortriptyline

Parnate/Tranylcypromine

Paxil/Paroxetine

Pristiq/Desvenlafaxine

Prozac/Fluoxetine

Remeron/Mirtazapine

Tofranil/Imipramine

Trintellix

Viibryd/Vilazodone

Vivactil/Protriptyline

Wellbutrin/Bupropion

Zoloft/Sertraline

Melitor (Agomelatine)

Thymanax (Agomelatine)

Valdoxan (Agomelatine)

Calculation of how many antidepressants taken

We Are In-Network For TMS Services With:* This field is required.We do not accept insurance for any service except to treat depression with TMS.

Aetna (In-Network)

Anthem (In-Network)

Availity (In-Network)

Beacon - Carelon (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)

Kaiser (Available in Modesto Area Only)

MHN (In-Network)

Magellan (In-Network)

Medi-Cal (Only in Santa Clara & Stanislaus County)

Medicare NOT ACCEPTING

Optum (In-Network)

Tri-Care (In-Network)

Tri-West (In-Network)

United (In-Network)

Uninsured

Other

Check insurance coverage for these services?* This field is required.

Yes

Would you like to be added to our mailing list?* This field is required.

Yes

Thank you for your interest. Click here to clear your data.

Kaiser coverage is limited to Modesto/Turlock/Merced area. Do you within with area?* This field is required.

Yes

Sorry, No Insurance Coverage

TMS to treat Major Depression is the only Service we accept insurance for. 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+)

Navigating insurance can be frustrating. We are in-network with all commercial insurance plans in California and will handle all your paperwork and prior authorization.

Patients often receive incorrect information from the insurance company's customer service. They might be told they have coverage without checking all requirements. We can help you prepare your inquiries to ensure you get accurate coverage details.

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

Would you like to be added to our mailing list?* This field is required.

Yes

Thank you for your interest. Click here to clear your data.

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

Would you like to be added to our mailing list?* This field is required.

Yes

Thank you for your interest. Click here to clear your data.

Please Review Our Fees Before Making an Appointment.

Self-Pay Fees (For those without insurance coverage) starts at $3,000 and up. For detailed pricing, please visit our website. https://www.brainwellnesscenter.com/insurance___costs/

We encourage all potential patients to review our fee structure before making an appointment to avoid any disappointment or misunderstanding.

After reviewing the cost of our services, would you still like to proceed?* This field is required.

Yes

Would you like to be added to our mailing list?* This field is required.

Yes

Thank you for your interest. Click here to clear your data.

How did you hear about us?* This field is required.

Doctor Referral

Google/Search Engine

Family/Friend

Facebook or other Social Media

Other

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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Appointment Request / Insurance Check