TMS (Transcranial Magnetic Stimulation)

Medication Free Treatment option for Depression, Anxiety and OCD

TMS of Johnson City/Crestpoint Psychiatric: Please complete this form and submit to enable us to obtain prior authorization from your insurance carrier for your TMS/SPRAVATO treatment.

Full Name

Date of Birth*

Cell Phone Number*

Email Address*

Home Address (Street, City)*

Home Address (Zip code, State)*

Health Insurance Carrier*

Insurance ID Number*

Attach a copy of the Front of your Insurance Card*

Who is the primary on the insurance?

Self
Spouse
Parent

Full Name and Date of Birth of the primary Insured. If you are the primary, type "self".*

Please answer the questions below.

Are you interested in ESKETAMINE treatment for depression?

YES
NO

Are you interested in Transcranial Magnetic Stimulation (TMS) for depression or anxiety?

YES
NO

Have you ever taken Amitriptyline, Nortriptyline, clomipramine, Doxepin? If “YES”, please list.*

Have you ever taken Lexapro, Prozac, Celexa, Lexapro, Zoloft, Paxil? If “YES”, please list.*

Have you ever taken Pristiq, Effexor, Cymbalta, Wellbutrin, Trintellix? If “YES”, please list.*

Have you ever taken Latuda, Rexulti, Remeron, Viibyrd, Elavil, Abilify? If “YES”, please list.*

Did you stop taking psychiatric medications because of side effects?

Yes
No

List the side effects you had from taking psychiatric medications.*

List your current Psychiatric Medications.*

Have you ever been in counselling or therapy?

Yes
No

Are you currently in counselling or therapy?

Yes
No

If are currently in counselling, do you attend sessions weekly, biweekly, or once a month? “N/A” if None.*

Name of Therapist and phone number. If none, type "N/A"*

Do you have any metal implants (brain clips, brain stent, shrapnel, bullet fragments) in the brain/head or neck area?

Yes
No

Do you have a history of epilepsy or seizures?

Yes
No

Do you have any implanted neurostimulator (e.g., Deep brain stimulator, epidural or subdural nerve stimulator)?

Yes
No

Do you have any cochlear implants (inside your ears)?

Yes
No

Do you have any hearing problems or ringing in my ears?

Yes
No

Do you have a cardiac pacemaker or any intracardiac or intravascular lines or metal in my body?

Yes
No

Have you ever had a brain bleed or any blood vessel/bleeding problems?

YES
NO

Have you been diagnosed with Bipolar disorder?

Yes
No

Have you been diagnosed with Schizophrenia ?

Yes
No

TMS treatment requires you to come into the office daily (5 days a week) for 6 weeks. Can you commit to this?

Yes
No
N/A

Intranasal ketamine treatment requires that you MUST have a designated driver who will pick up you from the office after your treatment as you are NOT allowed to drive for 24 hours after each treatment session. Do you have someone that you can designate as YOUR DRIVER?

YES
NO
N/A

What is TMS?

What is TMS (Transcranial Magnetic Stimulation)?

Transcranial magnetic stimulation (TMS) is a non-invasive treatment that uses repetitive magnetic pulses to stimulate nerve cells in the brain to improve symptoms of depression.
During a TMS session, an electromagnetic coil is placed against the scalp. The electromagnet pulse stimulates nerve cells in the region of your brain involved in mood control and depression.¹
TMS Therapy is typically used when other depression treatments haven’t been effective.

Is TMS covered by my insurance?

TMS is covered by most insurance providers including Medicare (and by Medicaid in some states). Prior authorization is typically required for insurance coverage. Your physician will manage this process. Typically, treatment with antidepressant medications and psychotherapy may be needed before insurance will authorize TMS Therapy.

Who can get TMS treatment?

TMS Therapy is indicated for the treatment of Major Depressive Disorder in adult patients who have failed to achieve satisfactory improvement from prior antidepressant medication in the current episode.

Are there any side effects to TMS Therapy?

TMS has few known side effects. The most common side effects are mild scalp discomfort or headaches during treatment, but normal activities can typically be resumed immediately after treatment.

What does TMS feel like?

The magnetic coil which delivers TMS is positioned on the head. You will hear a clicking sound and feel a tapping sensation on your head when the magnetic pulses are delivered. Many patients watch television or read during treatment.

How long will it take for the treatment to work?

This will vary from person to person.
It is commonly reported that patients need 30 to 36 sessions of TMS to feel relief from their depression symptoms. In clinical trials, approximately 58% of treatment-resistant patients responded positively to rTMS therapy.

Is TMS safe?

TMS has over two decades of clinical and scientific research supporting its safe use and application. FDA-cleared for the treatment of MDD, TMS Therapy is an effective, non-invasive, outpatient treatment, with few known side effects.

Who is not a candidate for TMS?

TMS Therapy is well tolerated for most. However, not all patients are appropriate candidates for TMS Therapy.
For example, patients with a history of seizures or who have metal implants or objects in or near their head are not appropriate candidates for TMS Therapy. To determine if TMS Therapy may be right for you, your supervising doctor or psychiatrist will carefully screen for the presence of medical conditions or metal objects which may make TMS unsuitable.

What is the success rate of TMS?

On average, three out of four TMS patients with major depression experience powerful positive effects from TMS, and of those patients, about half experience a complete remission of their symptoms for up to a year after just one course of treatment!

Listen to Mr. Rod's experience with Transcranial Magnetic Stimulation treatment.

Dr. Aimua is a diplomate of the American Board of Psychiatry and Neurology with over a decade of clinical experience providing individualized psychiatric care through medication management combined with different psychotherapeutic interventions to address a broad range of DSM 5 psychiatric syndromes.

Faith Aimua, M.D., FAPA

Physician

206 Princeton Road, STE 18, Johnson City, Tennessee, United States

TMS (Transcranial Magnetic Stimulation)

Medication Free Treatment option for Depression, Anxiety and OCD

INTAKE FORM

F.A.Q

What is TMS (Transcranial Magnetic Stimulation)?

Is TMS covered by my insurance?

Who can get TMS treatment?

Are there any side effects to TMS Therapy?

What does TMS feel like?

How long will it take for the treatment to work?

Is TMS safe?

Who is not a candidate for TMS?

What is the success rate of TMS?

Patient Testimonial

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