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Spravato® PROVIDER REFERRALS

Welcome to our Spravato Provider Referral Form

We are an approved Spravato facility

We are an adjunct treatment clinic, meaning, we are not a therapist office. We partner with providers who don’t offer this treatment at their facility, but who would like to refer their patients for this treatment option.

If you are a provider looking to refer your patient, please fill out the below form or you can print our Provider Referral form, fill it out and email it to ivketamineofnwa@gmail.com.

Additional Spravato Provider Resources

Spravato Website: Provider Resource page

Spravato Provider Referral Form

PROVIDER INFORMATION

Provider Name and Credentials *

Provider Phone Number

(###)

###

####

Provider Email *

PATIENT INFORMATION

Patient Name *

First Name

Last Name

Patient Date of Birth *

YYYY

Patient Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Patient Phone Number *

(###)

###

####

Patient Email *

Patient Diagnosis *

This is the only option currently, so it has been pre-populated for you.

ICD-10 Code *

This is the only option currently, so it has been pre-populated for you.

Date of Diagnosis *

YYYY

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.

1. Medication (List name and dose) *

2. Medication (if applicable, list the name and dose)

3. Medication (if applicable, list the name and dose)

4. Medication (if applicable, list the name and dose)

5. Medication (if applicable, list name and dose)

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.

1. Medication (List name, dose, date started, date stopped) *

2. Medication (List name, dose, date started, date stopped) *

3. Medication (List name, dose, date started, date stopped)

4. Medication (List name, dose, date started, date stopped)

5. Medication (List name, dose, date started, date stopped)

Please copy and paste last clinical notes. Additionally, provide any relevant clinical notes below (history and physical) *

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

1. Little interest or pleasure doing things? *

0 = Not at all

1 = Several days

2 = Nearly half the days

3 = More than half the days

2. Feeling down, depressed, or hopeless *

0 = Not at all

1 = Several days

2 = Nearly half the days

3 = More than half the days

3. Trouble falling or staying asleep, or sleeping too much *

0 = Not at all

1 = Several days

2 = Nearly half the days

3 = More than half the days

4. Feeling tired or having little energy *

0 = Not at all

1 = Several days

2 = Nearly half the days

3 = More than half the days

5. Poor appetite or overeating *

0 = Not at all

1 = Several days

2 = Nearly half the days

3 = More than half the days

6. Feeling bad about yourself or that you're a failure or have let yourself or your family down *

0 = Not at all

1 = Several days

2 = Nearly half the days

3 = More than half the days

7. Trouble concentrating on things, such as reading the newspaper or watching television *

0 = Not at all

1 = Several days

2 = Nearly half the days

3 = More than half the days

8. Moving or speaking so slowly that other people could have noticed. Or the opposite, being so fidgety or restless that you have been moving around a lot more than usual *

0 = Not at all

1 = Several days

2 = Nearly half the days

3 = More than half the days

9. Thoughts that you would be better off dead, or thoughts of hurting yourself *

0 = Not at all

1 = Several days

2 = Nearly half the days

3 = More than half the days

Total Score (Add up your patient's answers from #1-9 for a total) *

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.

I agree to the above statement

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.

Front of insurance card

Back of insurance card

Thank you!

EMAIL INSURANCE CARDS

Patient health questionnaire

Welcome to our Spravato Patient Health Questionnaire Form

Please fill out the below form on behalf of the patient you are referring for Spravato. When you come to the questionnaire at the end, you’ll provide a total score. If you experience any issues, please email ivketamineofnwa@gmail.com. Once we have received the completed form, we will reach out to the patient and ask them to email us with a copy of their insurance card (front and back).

PATIENT INFORMATION

Patient Name *

First Name

Last Name

Date of Birth (mm/dd/yyyy) *

YYYY

Patient Phone Number

(###)

###

####

Patient Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Patient Email *

Caregiver's Name (if applicable)

Caregiver's Phone Number (if applicable)

MEDICAL INFORMATION

Mental Health Provider *

Mental Health Provider Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mental Health Provider Phone *

(###)

###

####

Mental Health Provider Fax

(###)

###

####

Mental Health Provider Email *

The patient has been diagnosed with *

If you haven't been officially diagnosed with one of these two options, please stop filling out this form. You don't meet the current requirements for Spravato.

Treatment Resistant Depression

Major Depressive Disorder

Medical/Treatment History *

MEDICATION INFORMATION (Provide ALL necessary details - insurance won't approve without)

Please list the name, dosage and start date for any current mental health medications (must have at least one current oral antidepressant medication) *

Please list the name, dosage, start date and stop date for any previous mental health medications (must have tried and failed at least two previous mental health medications) *

PATIENT HEALTH QUESTIONNAIRE

Please rate the patient from 0-3 in this next section. At the end of the nine questions, total up the score. Scoring: 0 = Not at all, 1 = Several days, 2 = Nearly half the days, 3 = More than half the days

1. Little interest of pleasure doing things? *

0 = Not at all

1 = Several days

2 = Nearly half the days

3 = More than half the days

2. Feeling down, depressed, or hopeless *

0 = Not at all

1 = Several days

2 = Nearly half the days

3 = More than half the days

3. Trouble falling or staying asleep, or sleeping too much *

0 = Not at all

1 = Several days

2 = Nearly half the days

3 = More than half the days

4. Feeling tired or having little energy *

0 = Not at all

1 = Several days

2 = Nearly half the days

3 = More than half the days

5. Poor appetite or overeating *

0 = Not at all

1 = Several days

2 = Nearly half the days

3. More than half the days

6. Feeling bad about yourself or that you're a failure or have let yourself or your family down *

0 = Not at all

1 = Several days

2 = Nearly half the days

3 = More than half the days

7. Trouble concentrating on things, such as reading the newspaper or watching television *

0 = Not at all

1 = Several days

2 = Nearly half the days

3 = More than half the days

8. Moving or speaking so slowly that other people could have noticed. Or the opposite, being so fidgety or restless that you have been moving around a lot more than usual *

0 = Not at all

1 = Several days

2 = Nearly half the days

3 = More than half the days

9. Thoughts that you would be better off dead, or thoughts of hurting yourself *

0 = Not at all

1 = Several days

2 = Nearly half the days

3 = More than half the days

Total Score (Add up your answers from #1-9 for a total). *

Thank you!

Spravato Provider Referral Form

Spravato Patient Health Questionnaire

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Ketamine Clinic of NWA

5230 Willow Creek Drive,

Springdale, AR, 72762,

United States

479-927-3100 ivketamineofnwa@gmail.com

Hours

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Tue 8am-5pm

Wed 8am-5pm

Thu 8am-5pm

Fri 8am-12pm

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