Ect Request Form - Blue Cross Blue Shield Of New Mexico
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1Electroconvulsive Therapy (ECT)
ECT REQUEST FORM
Provider must call BCBSNM at 888-898-0070 to verify benefits.
Fax to BCBSNM at 877-361-7659, or fax at 312-946-3737.
Date______________________
Check One:
c Initial Request
c Concurrent
c Discharge
Patient Name___________________________________________________
Date of Birth__________________________________________________
Subscriber Name________________________________________________
Subscriber ID #______________________ Group #___________________
Facility/Provider Name _______________________________________
NPI#___________________________________________________
Address_______________________________________________________
City___________________________State________ Zip_______________
Primary MD Full Name ____________________________________________
MD NPI#_____________________________________________________
Address_______________________________________________________
City___________________________State________ Zip_______________
UR/Contact Name________________________________________________
Phone #_________________________Fax #________________________
ECT History: Any Past ECT?
c Yes
c No
ECT in the last 6 months?
c Yes
c No
Past Frequency?___________________________________ (x per week/month)
Brief Details of ECT to Date: _________________________________________
Is this a transition after IP ECT?
c Yes
c No
Current ECT Plan-Frequency:____________________________ (x per week/month)
Visits Requested
: c 90870 #________
(CPT Code)
Requested ECT Auth Start Date: ___________________________________
Tentative end date of treatment:___________________________________
Current DX — Please include all DSM 5 and/or medical diagnoses that apply.
Code #: _______________________ DX Name: ________________________________ Specifier: _____________________________________
Code #: _______________________ DX Name: ________________________________ Specifier: _____________________________________
Code #: _______________________ DX Name: ________________________________ Specifier: _____________________________________
Code #: _______________________ DX Name: ________________________________ Specifier: _____________________________________
Code #: _______________________ DX Name: ________________________________ Specifier: _____________________________________
Medications _________________________________________________________________________________________________________________
Current Clinical Presentation/Risk Factors (Substance abuse: Include last date of use) __________________________________________________________________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
Previous MH/CD Treatment _______________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
Current Treatment Goals _________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
Discharge Plan/Summary _____________________________________________________________________________________________
_____________________________________________________________________________________________________________
Additional clinical information can be faxed with this form if needed.
My signature confirms that I am providing the requested services:
Signature ___________________________________________________________ Date _________________
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
82175.0915
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