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Behavioral Health Service Request Form
Electroconvulsive Therapy Services as Covered
Please Submit to the Dedicated Fax Line Below
Georgia Medicare
Medicare Only Members: 1-877-892-8213
Dual Eligible Members (Members with Medicare & Medicaid Policies): 1-855-292-0233
Discharge Planning: 1-855-776-9464
MEMBER INFORMATION
Last Name
First Name, Middle
Initial
Date of Birth
Phone
Number
Wellcare ID Number
Gender
Male Female
Third-Party
Insurance
Yes No
If Yes, please attach a copy of the insurance card. If the card
is not available, provide the name of the insurer, policy type
and number.
Languages
Spoken
ORDERING PHYSICIAN/PRACTITIONER INFORMATION
Last Name
First Name
NPI Number
Wellcare ID
Number
Type
PCP Specialist
Specialty
Participating
Yes No
Phone Number
Fax Number
Street
Address
City,
State
ZIP
Name of Requestor
Office Contact (if Different)
TREATING PROVIDER/PRACTITIONER INFORMATION
Last Name
First Name
NPI Number
Wellcare ID
Number
Participating
Yes No
Discipline/Specialty
Street
Address
City,
State
ZIP
Phone
Number
Fax Number
Office Contact
FACILITY/AGENCY INFORMATION
Name
Facility ID
NPI Number
Street
Address
City,
State
ZIP
Phone
Number
Fax Number
Office Contact
Service Type Requested
List REV/CPT/HCPCS Code(s) and Number of Each Requested
Initial Inpatient ECT
Concurrent Inpatient ECT
Initial Outpatient ECT
Ongoing Maintenance ECT
Service Request Start Date:
Diagnosis Code and Description
Indicate any change in diagnostic presentation
Primary
Diagnosis
Secondary
Diagnosis
Medical
Diagnoses
PRO_51925E Internal Approved 02102020
©Wellcare 2022
GA0PROFRM51925E_0000
–
Behavioral Health Service Request Form
Electroconvulsive Therapy Services as Covered
REQUEST SPECIFICATION AND CLEARANCE
ECT in past 6 months?
Yes
No
ECT used in the past?
Yes
No
Number of previous sessions
overall?
What was the treatment outcome of past ECT?
Date of second opinion by Board
Certified Psychiatrist and MD Name:
Date of Pre-ECT
Lab Work:
Date of EKG:
Date of
Anesthesiologist
Clearance:
Date of Medical
MD/Assessment
Clearance:
Any Labs not WNL? Explain.
Any additional clearance needed/provided? Explain.
CLINICAL RATIONALE
Is ECT being performed for outpatient maintenance? If so, describe where and how the member will be safely monitored after treatment.
What courses of medication have been tried and failed prior to requesting ECT? ( List at least 2.) And over what period of time?
Provide a thorough overview of all medical conditions.
Provide a thorough explanation of why ECT is the best course of treatment for this member at this time.
CURRENT MEDICATIONS (Psychotropic and Medical)
Medication
Dosage
Frequency
Adherent?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Any medication contraindications?
If yes, describe.
PRO_51925E Internal Approved 02102020
©Wellcare 2022 GA0PROFRM51925E_0000
