Special Services Referral

New Special Services Referral

Submit a referral for Spravato, TMS, or IV Ketamine services. The special services team will begin the enrollment process, verify insurance/prior authorization, and order necessary materials.

Service Selection *

Select one or more services for this referral

Spravato

Esketamine nasal spray
Insurance + Prior Auth
REMS required

TMS

Transcranial Magnetic Stimulation
Insurance or Private Pay $200/session
36-session course

IV Ketamine

Ketamine infusion therapy
Insurance or Private Pay $400/session
Weight-based dosing

REMS Enrollment Required: Spravato requires enrollment in the Janssen REMS program before treatment can begin. The special services team will handle REMS paperwork and coordinate with the patient. Insurance + prior authorization is mandatory — no private pay option.

36-Session Course: Standard TMS treatment is 36 sessions over ~7 weeks. The team will coordinate prior authorization if insurance, or set up private pay at $200/session. Cap supply ($50/cap, FREE for Medicare) will be ordered upon approval. Two failed medication trials typically required for insurance approval.

IV Ketamine Infusion: Sessions require continuous vitals monitoring. Weight-based dosing at 0.5mg/kg. Patient must have someone to drive them home. Insurance coverage varies — private pay option available at $400/session. The team will verify coverage and order vial supply.

Referring Provider

Your information as the ordering/referring provider

Provider Name *

NPI

Referring From

Date of Referral

External Practice Details

Practice / Facility Name *

Practice Phone

Practice Fax

Provider Email

Practice Address

Patient Information

Demographics and contact details

First Name *

Last Name *

Date of Birth *

Phone *

Preferred Language

Emergency Contact

Weight (kg)

Required for IV Ketamine dosing (0.5mg/kg)

Allergies

Insurance & Payment

Insurance

Upload cards + enter plan info

Private Pay

TMS $200 · Ketamine $400/session

Insurance Card Photos

Front of Card

Click or drag to upload · JPG, PNG, PDF

Back of Card

Click or drag to upload · JPG, PNG, PDF

Insurance Carrier *

Member / Policy ID

Group Number

Plan Name

Subscriber Name

Subscriber DOB

Diagnosis *

Select primary and any secondary diagnoses — click to toggle

Common Diagnoses

F33.1 — MDD, Recurrent, Moderate

F33.2 — MDD, Recurrent, Severe

F32.1 — MDD, Single Episode, Moderate

F32.2 — MDD, Single Episode, Severe

F31.31 — Bipolar I, Depressed, Moderate

F31.32 — Bipolar I, Depressed, Severe

F33.0 — MDD, Recurrent, Mild

F41.1 — Generalized Anxiety Disorder

F43.10 — PTSD

F34.1 — Dysthymia

F60.3 — Borderline Personality Disorder

F40.10 — Social Anxiety Disorder

Additional ICD-10 Code

Diagnosis Notes

Treatment History

Prior medication trials and treatment attempts — important for insurance authorization

Patient has failed 2+ adequate medication trials

Patient has tried psychotherapy/CBT

Patient has active suicidal ideation

Patient is on a current antidepressant

History of substance use disorder

History of uncontrolled hypertension

Failed Medications List

Insurers typically require documentation of 2+ failed adequate trials for Spravato and TMS prior authorization

Insurance & Payment

Coverage details for the special services team to verify

Preferred Payment Type

Insurance + Prior Auth

Team will verify benefits and obtain prior authorization. Required for Spravato.

Private Pay

TMS $200/session · IV Ketamine $400/session · No prior auth needed

Insurance Carrier

Member / Policy ID

Group Number

Authorization Status

Urgency & Notes

Priority level and any additional clinical information

Urgency Level

Routine

Standard timeline
5–10 business days

Urgent

Expedite enrollment
2–3 business days

STAT

Immediate attention
Same/next day

Clinical Notes for Special Services Team

PHQ-9 Score (Most Recent)