Insurance Authorization - For rTMS Therapy Insurance networks commonly require prior authorization before you begin treatment. In an effort to help protect each of our patients, we attempt to ensure appropriate authorization is obtained from your health insurance company prior to treatment.
Most insurances will require the following:
•A diagnosis of depression (moderate to severe)
•A minimum of 2 to 4 antidepressant trials with little or no benefit from symptoms or medication discontinuation due to side effects.
•A history of psychotherapy (therapists, counselor, group therapy, outpatient therapy, extended visits with a psychiatrist, or psychologists)
•No history of seizures
•No rTMS Therapy treatment contraindications
•Insurance companies require medical record documentation of all of the above, including other qualifying information, in order to obtain prior authorization for rTMS therapy services. The TMS Collaborative will request your medical records from your behavioral health care providers in order to have this information on file and for insurance pre-authorization.
The TMS Collaborative will submit a prior authorization to your insurance upon receipt of all required documentation from you and your current or previous behavioral health care providers. Therefore, by signing this form you grant permission for The TMS Collaborative to submit a prior authorization request to your insurance provider for any treatment services and/or for services to be provided to you by one of our physicians or healthcare providers? By signing below, I acknowledge that The TMS Collaborative will submit a prior authorization to my insurance upon receipt of all required documentation from me and or my current or previous behavioral health care providers. I provide permission for The TMS Collaborative to submit a prior authorization request to my insurance provider for TMS therapy (transcranial magnetic stimulation) and/or for services to be provided to you by one of our physicians or healthcare providers.
Insurance and Financial Responsibility Information: By signing this form, you acknowledge that your insurance coverage, notification of any pre-authorization requirements, and terms of coverage are ultimately your responsibility. You acknowledge that insurance verification checks may not always reflect recent insurance claims, coverage of benefits, or other information. We make every attempt to verify your benefits and obtain preauthorization and will communicate this to you. If it is not provided or different from what is communicated to us by your insurance provider, you understand that benefits checks and pre-authorization are not a guarantee of payment. Pre-authorization is intended for your benefit and to help ensure payment from your insurance provider. If pre-authorization is obtained, but your insurance provider rejects services, you will be responsible for payment of services received. However, if insurance changes occur during the course of treatment, it is your responsibility to notify our office of these changes. In some instances, clients may receive a statement due to insurance changes or other reasons. We accept payment via credit card, cash, or health savings card (HSA).
Cancellation Policy: For cancellations made 24 hours or more in advance, no charge will be incurred by the patient for a canceled appointment. If a patient does not call within 24 hours to cancel their appointment, they will be charged $100. If a patient does not call to inform us they cannot attend their appointment and does not show up to their appointment, they will incur a no-show fee of $100. For the TMS evaluation conducted prior to TMS Therapy starting, a charge of $125 will be incurred for cancelling within 24 hours of the scheduled appointment and for a missed appointment. We understand that emergencies and unexpected events occur. In those cases, please call the office as soon as you are able to explain to the staff what occurred and they will determine whether you are subject to a cancellation fee or not. By signing below, I understand and acknowledge The TMS Collaborative PLLC's cancellation policy and the fees associated with it.
Patient Acknowledgment: By signing this form, you’re acknowledging to the best of The TMS Collaborative PLLC's ability they have answered your treatment-related questions. I am also aware of the HIPAA Notice and Patient Privacy Act. I am informed of The TMS Collaborative Hearing Protection Policy and I understand I may elect to decline to wear earplugs during treatment.
Any treatment-related questions I had prior to treatment were asked and answered to my satisfaction. If I am not aware of any, or all of the above notices or policies, I will request a further explanation from The TMS Collaborative prior to acknowledging this document. I also agree to not hold The TMS Collaborative and each of its employees and physicians liable from any adverse side effects or events that may result from any and all of my interventional psychiatry treatments with The TMS Collaborative. I fully understand the indications for and any side effects of rTMS Therapy including an explanation of clinic treatments I am seeking for major depression or any other diagnoses. For the therapy I am seeking, I have had all of my questions and/or concerns answered. Therefore, I authorize The TMS Collaborative to communicate with my health insurance company and any clinicians that I have received or am seeking treatment at The TMS Collaborative. Therefore, for the purpose of any pre-authorization and for any other purposes that may arise as a result of my relationship with The TMS Collaborative, my signature below acknowledges that I have read or I have waived the right to read The TMS Collaborative’s guide for any of their therapies.