TMS Authorization to Release Information

Patient name

First Name

Last Name

Patient Phone Number

Patient Email

Patient address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Provider/clinic name

Provider Phone Number

Provider Fax Number

Provider address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

I hereby authorize the provider named above to release the following information to NBCG, LLC for the purpose of determining or confirming whether Transcranial Magnetic Stimulation (TMS) therapy is an appropriate and medically necessary treatment for me: Psychiatric diagnoses - Intake note and most recent visit notes OR Clinical summary - Psychiatric medication history including dosage, dates of therapy, and outcomes - Current medication list - Recent diagnostic measurement scores (e.g.PHQ-9) - Psychotherapy history (dates, duration, frequency, outcomes) - ECT Treatment dates and outcomes, if applicable Please send records to Neurobehavioral Center for Growth at admin@neurobcg.com or to our dedicated fax @ 801 295 5537. Our office phone number is 801 683 1062. Our psychiatrist or psychologists are avaiable to discuss concerns with the primary care physician or psychiatrist as needed. I understand this information may be redisclosed by NBCG, LLC for the purpose of requesting authorization from my insurance plan for TMS therapy. This authorization may be revoked at any time by my written statement except to the extent that action has already been taken on it. It is automatically revoked 30 days after the termination of the therapeutic relationship.

TMS Authorization to Release Information

Find a Qualified Mental, Behavioral (ABA), Speech or Psychiatric Medical Provider Located Near You.

CONTACT US

e: admin@neurobcg.com | t: 801-683-1062 | f: 801-295-5537