3545 N.W. 58th St., Ste. 600, Oklahoma City, OK 73112
Phone: 405-717-8879 or 800-543-6044, ext. 8879
Fax: 1-405-949-5459 or 1-405-949-5501


This form must be completed and accompany all requests. Incomplete forms will not be reviewed.


 No   Yes
If yes, list dates:

 No   Yes
If yes, list dates:
 Alcohol or drug use
 Metal implant in or around head
 Implanted devices
 Suicidal ideations
 Neurological condition
 Seizure disorder
 Severe cardiovascular disease

Antidepressants — Trials of at least four different antidepressants from a minimum of two different classifications.






** All information is required for review. Information provided is private and confidential. **

NOTE: These benefits are applicable only if the patient is an eligible enrolled member of a HealthChoice plan. All benefits are subject to the deductible, coinsurance and policy provisions. Please verify benefits and eligibility by calling the medical claims administrator toll-free at 800-323-4314.

MEDICARE PATIENTS: If HealthChoice provides coverage that is supplemental to Medicare, all requested services must be approved by Medicare. The Medicare EOB should be filed for claims processing.