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877. 725. 7751 Improving Lives ELECTROCONVULSIVE THERAPY ECT AUTHORIZATION REQUEST FORM Please print clearly incomplete or illegible forms will delay processing. DEMOGRAPHICS PROVIDER INFORMATION Patient Name DOB SSN Patient ID Last Auth OP MH SA and/or IP SA List names and dates include hospitalizations Substance Use None Hospital where ECT will be performed Professional Credential MD PhD Other Physical Address street address city state zip code Phone Fax TPI/NPI PREVIOUS BH/SA TREATMENT...
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