933154 04/2020
INT_20_85393_C
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Please fax completed form and accompanying documentation to the Behavioral Health Unit at 1-866-949-4846
Medicare Advantage
Electroconvulsive Therapy (ECT) Initial Treatment Request
Customer Name: Today's Date:
Customer ID: Date of Birth:
Patient currently hospitalized:
Yes No
If yes, Inpatient Auth #: A
Diagnosis ICD 10 Codes
ECT Services Required
Contact Information
(_____)
Treating Provider Name:
Facility NPI #:
Phone:
Fax:
(_____)
Contact Person:
Facility:
Outpatient (# of units: _______)
Inpatient (# of units: _______) Total Units requested: _______)Requesting:
500 Great Circle, Nashville, TN 37228 Tel. 1-866-780-8546 Fax 1-866-949-4846
Order by attending.
Informed Consent signed by the customer.
Psychotropic medications have been tried and have failed or are contraindicated for this patient (include a list
of medication and start/end dates).
A second opinion has been obtained by another physician.
This patient has been cleared by a medical physician.
Signed anesthesiology consent.
Required Documentation
Please check to indicate that you have faxed the following information with this form.
Service start date: Service end date:
If requesting inpatient ECT: What prevents this service from being provided on an outpatient basis?
If requesting outpatient ECT: Does the patient have adequate post-treatment support for outpatient to safely
complete ECT on an outpatient basis?
This authorization is for medical necessity only and not a guarantee of payment. Eligibility is determined at the time the claim is received and benefits
are subject to the limitations and exclusions of the member's plan.
HIPAA Notice: The information contained in this form may contain confidential and legally privileged information. It is only for the use of the
individual or entity named above. If the recipient of this form is not the recipient addressed on the form, you are hereby notified that any
dissemination, distribution, or copying of the attached document(s) is strictly prohibited. If you have received this in error, please immediately
notify the sender by telephone and return the form to the sender.
