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Evernorth Transcranial Magnetic Stimulation (TMS) …

This form should be completed by the clinician who has a thorough knowledge of the Evernorth customer's current clinical presentation and his/her treatment history. Please note: The information contained in this form may be released to the customer or the customer's help expedite processing of this request , please complete all sections as specifically and clearly as email is secure and authenticated. Please do not send encrypted responses are preferred..Omissions, generalities, and illegibility will result in this request being returned for completion or Magnetic Stimulation (TMS) request FormEvernorth Provider website FOR COMPLETING THIS form :924445 Rev.

Transcranial Magnetic Stimulation (TMS) Request Form (Continued) 924445 Rev. 08/2020 Page 2 of 3. 6. In the space below, please provide a description of the customer's symptoms and functional impairments: Onset of symptoms/ precipitating events: Current symptoms and functional impairments: 7.

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