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:

Phone #:

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?

Does the patient have one of the following ICD-10 Diagnosis codes? F32.2F33.2Other Diagnosis Code

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