PROVIDER INFORMATION

PATIENT INFORMATION

CURRENT MENTAL HEALTH MEDICATIONS (Must be on ONE for Spravato approval)

The patient must be on at least ONE mental health medication currently for Spravato approval. There are additional medication fields available if the patient is on more than one current mental health medication.

FAILED MENTAL HEALTH MEDICATIONS (Must have TWO failed medications during current episode)

For each failed medication, please list the name, dose, date started and the date stopped. Two are required for this section.

PATIENT HEALTH QUESTIONNAIRE (MOST RECENT)

Please provide the answers to the most recent patient health questionnaire for this patient. At the end of the nine questions, total up the patient's score.

0 = Not at all, 1 = Several days, 2 = Nearly half the days, 3 = More than half the days

CLINICAL NOTE AND AGREEMENT:

It is in my medical opinion, based on scientifically valid studies, using accepted protocols, that Spravato is likely to be beneficial to the patient's mental health. This patient has failed TWO or more appropriate medications during this episode of depression. Patient has no current substance abuse disorder or medical disorder that would disqualify the patient from Spravato.

PATIENT INSURANCE CARDS

SEND A COPY OF FRONT AND BACK OF PATIENT'S INSURANCE CARD

I Agree to Email a copy of the Patient's Insurance Card Front and Back to ivketamineofnwa@gmail.com. Once you have submitted this form, there is a box below where you can email the insurance cards, the email address show automatically pop up for you to make it easy.