Revised 20201104 CM-FRM-0717-001
CT Authorization
(Transcranial Magnetic Stimulation/Electroconvulsive Therapy)
Today's date:
Patient name: Phone:
ID number: Date of birth:
Member address:
Provider name/title:
Tax ID: _______ NPI: _____________________________________
Phone: Fax:
Contact name: Contact phone:
Diagnosis/ICD codes:
List all proposed CPT/HCPCS codes (including units):
Expected start date:
e clinical information below is mandatory to evaluate medical necessity and should be submitted along
with this form to GEHA:
ient history/evaluation (including tried and failed treatments).
Current presentation of symptoms.
Treatment plan (including frequency and total number of sessions requested).
Please fax completed form and supporting documents to GEHA’s Care Management Department at
816.257.3255 or 816.257.3515.*
Or mail documents to:
Care Management Department
P.O. Box 21542
Eagan, MN 55121
*If the patient lives in Delaware, Florida, Louisiana, Maryland, North Carolina, Oklahoma, Texas,
Virginia, Washington D.C., West Virginia or Wisconsin, do not complete form. Contact
UnitedHealthcare Choice Plus at 877.585.9643.
Questions: Call Care Management at 800.821.6136, ext 3100.
Payable benefits are subject to the terms and conditions of the Health Benefit Plan.