Patient Information: Last Name: New Patient Information First Name: Address: City: State: Zip: Ph#: Cell#: S.S.N: Email: May we contact you by email? Yes No Date of Birth: May we send you information about TMS Center of Colorado by email? Yes No Employer Information: Occupation: Employer: Address: City: State: Zip: Ph#: Reffering Professional Information Reffering Professional: Ph#: Address: City: State: Zip: Fax#: Second Refferal Source Information (if any): Reffering Professional: Ph#: Address: City: State: Zip: Fax#: Emergency Contact: Contact Name: Relationship to Patient: Address: City: State: Zip: Ph#: Cell#: INSURANCE INFORMATION: TMS Center of Colorado, LLC does not participate in network with most insurance plans. The patient is responsible for payment. Insurance Company: Subscriber Name: ID#: Insurance Company Address: City: State: Zip: Ph#: Fax#: For Office Use Only: Diagnosis Code(s): Primary Diagnosis Description: 4770 E. Iliff Avenue Suite, 224 Denver, Colorado 80222 rev. 02262014 Phone: 303.884.3867 Fax: 303.757.7994 info@tmscenterofcolorado.com www.tmscenterofcolorado.com
Treatment History Medications used in past episodes (check all that apply): Amitriptyline (Elavil) Anafranil (Clomipramine) Aripiprazole (Abilify) Bupropion (Wellbutrin) Buspirone (Buspar) Citalopram (Celexa) Clomipramine (Anafranil) Duloxetine (Cymbalta) Escitalopram (Lexapro) Fluoxetine (Prozac) Fluvoxamine (Luvox) Mirtazapine (Remeron) Olanzapine (Zyprexa) Pamelor (Nortriptyline) Paroxetine (Paxil, Paxil XR) Quetiapine (Seroquel XR) Sertraline (Zoloft) Tofranil (Imipramine) Trazadone (Desyrel) Venlafaxine (Effexor) Vilazodone (Viibryd) Other: Other: Other: Psychiatric Hospitalizations Not Applicable Date: # of Days: Hospital: Date: # of Days: Hospital: Date: # of Days: Hospital: Psychotherapy Is the patient currently in psychotherapy? Yes No If yes, for how long? What type? Has the patient received psychotherapy in the past? Yes No If yes, for how long? What type? Suicide Attempts Have you ever attempted suicide? Yes No # of attempts: Date(s) of attempt(s) 4770 E. Iliff Avenue Suite, 224 Denver, Colorado 80222 rev. 04162014 Phone: 303.884.3867 Fax: 303.757.7994 info@tmscenterofcolorado.com www.tmscenterofcolorado.com
Patient Name: CURRENT MEDICATIONS DOSAGE INSTRUCTIONS HOW LONG ON MED? 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. NOTES: 4770 E. Iliff Avenue Suite, 224 Denver, Colorado 80222 Phone: 303.884.3867 Fax: 303.757.7994 info@tmscenterofcolorado.com www.tmscenterofcolorado.com
TMS New Patient Information Record Yes No If you answer yes to any question fully describe below Do you have a cardiac pacemaker? Do you have an aneurysm clip? Do you have a vagal nerve stimulator? Do you have a cochlear implant? Do you have any other implanted device? Do you have any metallic objects in your body? If yes, describe: Have you ever had any metallic foreign body in your eye? If yes, describe: Do you have cancer? Do you have headaches? Have you ever had a seizure? Have you ever suffered a stroke? Do you have any cardiac disease? Do you have any infectious disease? Do you have any allergies? If yes, describe: Do you have a history of alcohol or drug abuse? Do you smoke? If yes, how many packs per day? How many years? Do you drink alcohol? If yes, how many drinks per week? Have you had any suicide attempts? If yes, how many? Do you have any current legal issues? Have you ever had an MRI of your brain? Do you have any other medical problems (past or present)? If yes, describe: Describe: Signature: Date: 4770 E. Iliff Avenue Suite, 224 Denver, Colorado 80222 rev. 04162014 Phone: 303.884.3867 Fax: 303.757.7994 info@tmscenterofcolorado.com www.tmscenterofcolorado.com
PATIENT HEALTH QUESTIONNAIRE-9 (PHQ-9) Over the last 2 weeks, how often have you been bothered by any of the following problems? (Use to indicate your answer) Not at all Several days More than half the days Nearly every day 1. Little interest or pleasure in doing things 0 1 2 3 2. Feeling down, depressed, or hopeless 0 1 2 3 3. Trouble falling or staying asleep, or sleeping too much 0 1 2 3 4. Feeling tired or having little energy 0 1 2 3 5. Poor appetite or overeating 0 1 2 3 6. Feeling bad about yourself or that you are a failure or have let yourself or your family down 0 1 2 3 7. Trouble concentrating on things, such as reading the newspaper or watching television 8. Moving or speaking so slowly that other people could have noticed? Or the opposite being so fidgety or restless that you have been moving around a lot more than usual 9. Thoughts that you would be better off dead or of hurting yourself in some way 0 1 2 3 0 1 2 3 0 1 2 3 FOR OFFICE CODING 0 + + + =Total Score: If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Not difficult at all Somewhat difficult Very difficult Extremely difficult Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute.
FINANCIAL POLICY FINANCIAL POLICY: COST: Initial Consultation is $250. This service is provided by Ted Wirecki, MD and will be billed by and should be paid to Ted Wirecki, MD, PC. Payment is due at the time of Consultation. The Initial Consultation may be covered by insurance but reimbursement will depend on your specific mental health insurance policy. As a courtesy, a claim will be submitted to your insurance carrier. Transcranial Magnetic Stimulation ( TMS ) therapy: TMS therapy is provided by TMS Center of Colorado, LLC. The Initial Course of therapy for self- pay patients is $8,000 for 20 visits. Up to an additional 10 treatments may be required for maximum benefit. These may be provided without additional cost to self- pay patients. Note: Payment is due in full at the time of scheduling the initial block of treatment. Additional treatments: $550 for Motor Threshold Measurement and $400 per treatment session Payment for TMS Therapy: As with most relatively new treatments and therapies, TMS therapy is not covered under most insurance plans and the patient is responsible for payment for the therapy (see below regarding filing for insurance reimbursement). We accept most forms of payment. Payment for the TMS therapy should be made to TMS Center of Colorado, LLC. If you are considering financing your treatment, there are companies that offer this service and we can provide you with contact information for a company that does so. Insurance Coverage and Reimbursement for Transcranial Magnetic Stimulation: Although most insurers do not cover TMS therapy at this time, some patients want to bill their insurance carrier to be certain. We will furnish you with a paid receipt that you can submit for reimbursement. Alternatively, as a courtesy, we will submit a claim for TMS therapy to your insurance carrier on your behalf. Even if we do so you are still responsible for payment of TMS therapy charges at the time of your initial treatment, in accordance with our charges for self- pay patients, discussed above. If you want to appeal a denial of TMS services, your insurance carrier may require a letter of medical necessity and we will furnish this on request. Please be aware that our charge to insurance may differ from our charge for self- pay patients. If your insurance carrier ultimately approves coverage of TMS therapy, we must collect any copayments and deductibles required under your insurance plan. In the few cases where The TMS Center has a contract with your insurance carrier, we will bill your carrier in accordance with the terms of the contract. Cancellation policy: In order for TMS Therapy to be effective, it must be performed on a routine basis for a minimum of 20 sessions/4 weeks (treatment is generally scheduled M- F). Missing any treatments could affect your response and is not advisable. We require seven (7) days notice prior to starting the initial (acute phase) treatment to cancel in order to receive a refund. No refunds will be given after this time (seven (7) days prior to starting the initial (acute phase) treatment block). Patient Acknowledgement: Patient Name: (print) Patient or Guardian s signature: Date:
Patient Consent for a Medical Procedure Off Label TMS Treatment This is a patient consent for a medical procedure called TMS Treatment. This consent form outlines the treatment that your doctor has prescribed for you or you have chosen to pursue, the risks of this treatment, the potential benefits of this treatment to you, and any alternative treatments that are available for you if you decide not to be treated with TMS Treatment. TMS Center of Colorado, LLC has explained the following information to me: a. TMS stands for Transcranial Magnetic Stimulation. TMS Treatment is a medical procedure. A TMS treatment session is conducted using a device called the TMS Treatment System, which provides electrical energy to a treatment coil or magnet that delivers pulsed magnetic fields. These magnetic fields are the same type and strength as those used in magnetic resonance imaging (MRI) machines. b. TMS Treatment is a safe and effective treatment for patients with depression who have not benefitted from antidepressant medications. c. Specifically, TMS Treatment has been shown to relieve depression symptoms in adult patients who have been treated with one antidepressant medication given at a high enough dose and for a long enough period of time but did not get better. d. At this time, there are no studies that show that TMS Treatment works for patients who did not get better after taking two or more antidepressant medications at a high enough dose and for a long enough period of time or who did not take any antidepressants during this current period of depression. e. During a TMS treatment session, the doctor or a member of their staff will place the magnetic coil gently against my scalp on the left front region of my head. The magnetic fields that are produced by the magnetic coil are pointed at a region of the brain that scientists think may be responsible for causing depression. f. To administer the treatment, the doctor or a member of their staff will first position my head in the head support system. Next, the magnetic coil will be placed on the left side of my head, and I will hear a clicking sound and feel a tapping sensation on my scalp. The doctor will then adjust the TMS Treatment system so that the device will give just enough energy to send electromagnetic pulses into the brain so that my right hand twitches. The amount of energy required to make my hand twitch is called the motor threshold.
Everyone has a different motor threshold and the treatments are given at an energy level that is just above my individual motor threshold. How often my motor threshold will be re-evaluated will be determined by my doctor. g. Once motor threshold is determined, the magnetic coil will be moved, and I will receive the treatment as a series of pulses, with a rest period of about 20 seconds between each series. Treatment is to the left front side of my head and will take about 20-45 minutes. I understand that this treatment does not involve any anesthesia or sedation and that I will remain awake and alert during the treatment. I will initially receive these treatments 5 times a week for 4 weeks (20 treatments) and I understand that additional treatments may be required in order to achieve maximum response. The treatment is designed to relieve my current symptoms of depression. h. During the treatment, I may experience tapping or painful sensations at the treatment site while the magnetic coil is turned on. These types of sensations were reported by about one third of the patients who participated in the research studies. I understand that I should inform the doctor or his/her staff if this occurs. The doctor may then adjust the dose or make changes to where the coil is placed in order to help make the procedure more comfortable for me. I also understand that headaches were reported in half of the patients who participated in the clinical trial for the device. I understand that both discomfort and headaches got better over time in the research studies and that I may take common overthe-counter pain medications such as acetaminophen if a headache occurs. i. The following risks are also involved with this treatment: The TMS Treatment System should not be used by anyone who has magnetic-sensitive metal in their head or within 12 inches of the magnetic coil that cannot be removed. Failure to follow this restriction could result in serious injury or death. Objects that may have this kind of metal include: Aneurysm clips or coils Stents Implanted Stimulators Electrodes to monitor your brain activity Ferromagnetic implants in your ears or eyes Bullet fragments Other metal devices or objects implanted in the head.
j. TMS Treatment is not effective for all patients with depression. Any signs or symptoms of worsening depression should be reported immediately to your doctor and/or the TMS Center of Colorado, LLC staff. You may want to ask a family member or caregiver to monitor your symptoms to help you spot any signs of worsening depression. k. Seizures (sometimes called convulsions or fits) have been reported with the use of other types of TMS devices. However, no seizures were observed with use of the TMS Treatment system in over 10,000 patient treatment sessions. l. Because the TMS Treatment system produces a loud click with each magnetic pulse I understand that I must wear earplugs or similar hearing protection devices with a rating of 30dB or higher of noise reduction during treatment. m. I understand that most patients who benefit from TMS Treatment experience results by the fourth week of treatment. Some patients may experience results in less time while others may take longer. n. I understand that I may discontinue treatment at any time. I have read the information contained in this Medical Procedure Consent Form about TMS Treatment and its potential risks. I have discussed it with TMS Center of Colorado, LLC staff who has answered all of my questions. I understand there are other treatment options for my condition available to me and this has also been discussed with me. I understand that TMS is currently approved for depression, however, the goal of my treatment would be for off-label indications and this has been explained to me. I, therefore, permit TMS Center of Colorado, LLC and its staff to administer this treatment to me. PATIENT NAME (PRINT): PATIENT SIGNATURE WITNESS DATE