Clearwave Referral Form
Patient Name
*
Patient Date of Birth
*
/
Month
/
Day
Year
Date
Patient Email Address
*
example@example.com
Patient Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Patient Gender
*
Please Select
Male
Female
Non-binary
Prefer not to say
Other
Patient Zip Code
*
Primary Diagnosis
Health Insurance (e.g., Aetna, BCBS)
Additional Patient Notes
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Referral Details
I'm referring my patient for
*
TMS Therapy
Spravato
Medication Management/Psychiatric Treatment
I'd like Clearwave to evaluate which treatment may be best for my patient
Closest Clearwave Location for Patient
*
Garden City
Hauppauge
Kingston
Latham
Middletown
Nanuet
New Rochelle
Poughkeepsie
Syracuse
Valhalla
No Preference/Not Sure
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Referring Provider Information
Referring Provider Name
*
Referring Provider Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Referring Provider Email
*
example@example.com
Referring Provider Specialty
Referring Provider Practice Location
TMS/Spravato Endorsement
Attesting the pre-requisites help us evaluate and advocate coverage for your patient for TMS/Spravato
The intended point in your referral is for TMS/Spravato to treat the patient’s treatment resistant depression, anxiety, OCD, PTSD symptoms and all things adjacent
Yes
No
The patient has had adequate trial of psychotherapy to address these symptoms without the desired outcome
Yes
No
The patient has failed multiple trials of psychotropic medications to address these symptoms without the desired outcome
Yes
No
The patient does not have a substance abuse disorder that would prohibit the use of TMS/Spravato
Yes
No
The patient has no standard contraindications (i.e. epilepsy, metal in the head, cardiac conditions) to the best of your knowledge that would prohibit the use of TMS/Spravato
Yes
No
Referring Provider Signature on Endorsement
Submit Referral
Submit Referral
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