HIPAA (Health Insurance Portability and Accountability Act) is a federal law that protects the privacy of your medical records and information. HIPAA limits who your health care providers can share your medical information with, unless you give your permission in writing by filling out an Authorization for Release of Information form.

 

TMS Solutions must have access to your medical records and information to act on your behalf to gain prior authorization for TMS Therapy.

 

Unfortunately, medical record sharing between providers is becoming increasingly more difficult and can hinder or prevent a patient from receiving needed treatment. If you, as a patient, have the ability to request your own medical records from past or current providers and/or pharmacies, please do so. You can email your records to the Prior Authorization department at PA@tmssolutions.com, or fax to 844-204-2233. Thank you.

AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION

This form is for use when such authorization is required and complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Standards and 42CFR Part 2.

I authorize the below named individual / company to disclose the health information indicated below.

* Therapy History - please provide the frequency and duration of the completed sessions as well as the treatment modality that was used.  We are not requesting access to individual notes.  A letter detailing the requested information is sufficient.

** Medication Lists for psychotropic prescriptions should include the beginning and ending dosage, month, and year the prescription began and ended. If side effects are known, please include those as well.

I authorize this information to be disclosed to and used by:

TMS Solutions
Attn: Prior Authorizations
Fax: 844-204-2233
Phone: 844-200-7011 ext. 6
Mail: 765 E. Holland Ave., Ste. 1, Spokane, WA 99218

The purpose of this authorization is for Continuation of Care.

This authorization ends 180 days from the date signed unless otherwise revoked. I expressly give permission for the release of the above noted mental health, drug, or alcohol treatment information.  

AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION

This form is for use when such authorization is required and complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Standards and 42CFR Part 2.

I authorize the below named individual / company to disclose the health information indicated below.

* Therapy History - please provide the frequency and duration of the completed sessions as well as the treatment modality that was used.  We are not requesting access to individual notes.  A letter detailing the requested information is sufficient.

** Medication Lists for psychotropic prescriptions should include the beginning and ending dosage, month, and year the prescription began and ended. If side effects are known, please include those as well.

I authorize this information to be disclosed to and used by:

TMS Solutions
Attn: Prior Authorizations
Fax: 844-204-2233
Phone: 844-200-7011 ext. 6
Mail: 765 E. Holland Ave., Ste. 1, Spokane, WA 99218

The purpose of this authorization is for Continuation of Care.

This authorization ends 180 days from the date signed unless otherwise revoked. I expressly give permission for the release of the above noted mental health, drug, or alcohol treatment information.  

AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION

This form is for use when such authorization is required and complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Standards and 42CFR Part 2.

I authorize the below named individual / company to disclose the health information indicated below.

* Therapy History - please provide the frequency and duration of the completed sessions as well as the treatment modality that was used.  We are not requesting access to individual notes.  A letter detailing the requested information is sufficient.

** Medication Lists for psychotropic prescriptions should include the beginning and ending dosage, month, and year the prescription began and ended. If side effects are known, please include those as well.

I authorize this information to be disclosed to and used by:

TMS Solutions
Attn: Prior Authorizations
Fax: 844-204-2233
Phone: 844-200-7011 ext. 6
Mail: 765 E. Holland Ave., Ste. 1, Spokane, WA 99218

The purpose of this authorization is for Continuation of Care.

This authorization ends 180 days from the date signed unless otherwise revoked. I expressly give permission for the release of the above noted mental health, drug, or alcohol treatment information.  

AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION

This form is for use when such authorization is required and complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Standards and 42CFR Part 2.

I authorize the below named individual / company to disclose the health information indicated below.

* Therapy History - please provide the frequency and duration of the completed sessions as well as the treatment modality that was used.  We are not requesting access to individual notes.  A letter detailing the requested information is sufficient.

** Medication Lists for psychotropic prescriptions should include the beginning and ending dosage, month, and year the prescription began and ended. If side effects are known, please include those as well.

I authorize this information to be disclosed to and used by:

TMS Solutions
Attn: Prior Authorizations
Fax: 844-204-2233
Phone: 844-200-7011 ext. 6
Mail: 765 E. Holland Ave., Ste. 1, Spokane, WA 99218

The purpose of this authorization is for Continuation of Care.

This authorization ends 180 days from the date signed unless otherwise revoked. I expressly give permission for the release of the above noted mental health, drug, or alcohol treatment information.  

AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION

This form is for use when such authorization is required and complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Standards and 42CFR Part 2.

I authorize the below named individual / company to disclose the health information indicated below.

* Therapy History - please provide the frequency and duration of the completed sessions as well as the treatment modality that was used.  We are not requesting access to individual notes.  A letter detailing the requested information is sufficient.

** Medication Lists for psychotropic prescriptions should include the beginning and ending dosage, month, and year the prescription began and ended. If side effects are known, please include those as well.

I authorize this information to be disclosed to and used by:

TMS Solutions
Attn: Prior Authorizations
Fax: 844-204-2233
Phone: 844-200-7011 ext. 6
Mail: 765 E. Holland Ave., Ste. 1, Spokane, WA 99218

The purpose of this authorization is for Continuation of Care.

This authorization ends 180 days from the date signed unless otherwise revoked. I expressly give permission for the release of the above noted mental health, drug, or alcohol treatment information.  

AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION

This form is for use when such authorization is required and complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Standards and 42CFR Part 2.

I authorize TMS Solutions to release the records that were produced during my TMS Therapy sessions and the corresponding dates of recorded encounters.

Please note, TMS Solutions will not release third party records, only records produced while receiving TMS Treatment at one of our clinics.

 

PLEASE RELEASE RECORDS TO:

AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION

Many of our patients allow family members such as their spouse, significant other, parents or children to call and request the result of tests, procedures and financial information. The requirements for HIPPA do not allow TMS Solutions to give this information to anyone without your consent. If you wish to have your medical information, any diagnostic test results and/or financial information released to any family members you must sign this form.

You have the right to revoke this consent, in writing, except where we have already made disclosures in reliance on your prior consent.

This information may be used to enable the persons I authorize to know and understand my condition and treatment or treatment options for treatment or consultation, for claims payment purposes, or related reasons.

This authorization ends 180 days from the date signed unless otherwise revoked. I expressly give permission for the release of the above noted information. 

Please consider this a formal request of copies of my medical records as allowed by the Health Insurance Portability and Accountability Act (HIPAA) and Department of Health and Human Services regulations.

I was treated by TMS Solutions and I am requesting copies of all health records related to my treatment.

I understand you may charge a reasonable fee for copying the records, but will not charge for time spent locating the records. Please mail the requested records to me at the above address. [If you request that the records be mailed, you may also be charged for postage.]

I look forward to receiving the above records within 30 days as specified under HIPAA. If my request cannot be honored within 30 days, please inform me of this by letter as well as the date I might expect to receive my records.

Please click the "Submit" button to transmit your paperwork to our Intake Department.