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Directions: Please fill out this form in its entirety (Any section with an * is required, info is critical for prior authorization) Once complete please return to the form via: Fax: 260-800-1512 or info@vikingpsychiatry.com
Referrer Information: *
Name
(Required)
First
Profession
(Required)
Email
(Required)
Phone Number
(Required)
Please check preferred method of communication:
(Required)
E-Mail
Office Phone
Patient Information: *
Name
(Required)
First
Date of Birth
(Required)
DD slash MM slash YYYY
MRN: (if BI patient):
(Required)
Phone Number
(Required)
Email
(Required)
Please check preferred method of communication:
(Required)
E-Mail
Phone
Condition for which rTMS is being requested:
(Required)
Depression
Phone
Other Indication
Patient Narrative * - Give a brief description of patient’s history (Please include any prior hospitalizations, TMS, and/or ECT)
(Required)
Past Medication Trials (please list all past medication trials for depression)
Diagnosis*
(Required)
Comments
(Required)
Secondary
(Required)
Comments
(Required)
Additional (if applicable)
(Required)
Comments
(Required)
Diagnoses (please list all diagnoses)
Past Medication Trials
(Required)
Medication
Dose
Response / Side Effects / Reason for Discontinuation:
Add
Remove
Current Medications (please list all current medications)
Current Medications
(Required)
Medication
Dose
Current Response / Side Effects
Add
Remove
Name
This field is for validation purposes and should be left unchanged.
