Refer a Patient

Working together for patients

If you feel your patient could benefit from TMS Therapy, please submit the completed form with the relevant clinical information. If fax is preferred, please download this form and fax to: (502) 792-7292.

Working together for patients

Patient Name(Required)

Phone #(Required)

Address

Date of Birth:

Insurance Provider

Insurance Phone #

Policy Number/ID

Referring Provider

Address

Office Phone #

Office Fax

Have you discussed TMS as a treatment option with the patient?

Yes

Does the patient have one of the following ICD-10 Diagnosis codes?

F32.2

F33.2

Other Diagnosis Code

Which clinic to submit the form?

Additional Notes