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ADDRESSOGRAPH OUTPATIENT ECT REFERRAL AND ORDER TO BE COMPLETED BY REFERRING PHYSICIAN Patient Name Date of Birth Insurance Company Policy Number DSM 5 Code ECT Rationale / Past Medication Trial Current

How to fill out outpatient ect referral and

How to fill out an outpatient ECT referral:

1. Start by obtaining the referral form from the appropriate medical facility or physician.
2. Read the instructions carefully to ensure you understand what information needs to be provided.
3. Begin by filling out your personal details, including your full name, date of birth, and contact information.
4. Provide information about your primary care physician or referring doctor, including their name, contact information, and any relevant identification numbers.
5. Specify the reason for the referral by describing your current condition, symptoms, and any relevant medical history.
6. If applicable, include any relevant test results, imaging reports, or medical records that support the need for the referral.
7. Indicate the preferred date and time for the outpatient ECT appointment, if applicable.
8. Sign and date the referral form before submitting it to the appropriate medical office or facility.

Who needs an outpatient ECT referral:

1. Individuals who have been diagnosed with severe mental health conditions such as treatment-resistant depression, bipolar disorder, or schizophrenia may require an outpatient ECT referral.
2. Patients who have not responded adequately to other treatments or medications for their mental health conditions may also be candidates for ECT and, therefore, need a referral.
3. Individuals who have received ECT in the past and require ongoing treatments as part of their mental health management may need a referral for routine outpatient sessions.

Please note that the exact requirements for an outpatient ECT referral may vary depending on the specific medical facility or physician involved. It is always best to consult with your primary care physician or mental health provider to determine the necessary steps for obtaining a referral.

For pdfFiller’s FAQs

What is outpatient ect referral and?

Outpatient ECT referral is a process where a healthcare provider refers a patient to receive electroconvulsive therapy as an outpatient.

Who is required to file outpatient ect referral and?

The healthcare provider or psychiatrist overseeing the patient's treatment is required to file the outpatient ECT referral.

How to fill out outpatient ect referral and?

To fill out the outpatient ECT referral, the healthcare provider must provide the patient's medical history, reason for referral, and any relevant clinical information.

What is the purpose of outpatient ect referral and?

The purpose of outpatient ECT referral is to facilitate the patient's access to electroconvulsive therapy as an outpatient, rather than as an inpatient.

What information must be reported on outpatient ect referral and?

The outpatient ECT referral must include the patient's demographics, medical history, reason for referral, diagnosis, treatment plan, and any relevant clinical information.

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