Forms and Policies
Below are links to our most frequently used intake paperwork. Our goal during this initial evaluation is to gain understanding of the reasons for your visit. Please take your time and fill out the intake information in detail. This information provides essential medical and social history for you that help us to determine what type of treatment road map should be developed for your individual needs.
This packet is five pages and includes a face sheet with questions about you and your insurance and a payment agreement with details of our billing procedures as well as an acknowledgement that you were given access to our HIPPA Confidentiality Notice. There is a HIPPA Confidentiality Notice copied here should you like to have a copy. The packet also includes an option release of information and a credit card authorization form, should you need either of these. All clients must complete this packet before their first visit. You can print it out and bring it with you, mail/fax/or email it to us, or arrive 20 minutes prior to your appointment to fill it out then.
Please note that all minors MUST be accompanied by a parent or guardian.
Please fill out a release for any other clinicians that you would like to be able to be consulted regarding your care.
TMS Forms: Patient Questionnaire
Patients, please fill out the questionnaire by clicking on the link above. After we recieve this information, our TMS Coordinator will contact you to review any additional information that we might need. Once we have your completed questionnaire, we will most likely ask you to fill out a Release of Information (link above) so that we may obtain records from previous prescribing providers. If clients meet the criteria for treatment by TMS of depression, the TMS Coordinator will then schedule you for a clinical consultation with a medical provider and we will gather benefit information from your insurance company. At the clinical consultation we will go over the details of TMS therapy with you, answer any questions you may have, and start the process of prior authorization of services with your insurance company (if warranted).
Our office does expect payment in full at the time of service. For your convenience we accept Visa, Mastercard, or personal checks. For clients with insurance coverage that we bill we will charge you your copay or estimated cost at each visit.
We do bill a variety of insurances for our clients. We are participating providers with Blue Cross Blue Shield, Allegiance, Medicaid, PacificSource, InterWest Healthcare, and the Health InfoNet Network. Some of our providers are participating with Medicare. At this time we are not accepting any new Medicare clients. Please bring your ID and insurance card to your first appointment and alert our office of any future changes in your insurance coverage.
If you have an insurance that we do not bill directly we will charge you in full for the appointment, but give you an insurance receipt that you can submit directly to your insurance for reimbursement.