Insurance Check- Appointment Request

Appointment Request - Insurance Check

I can help you to book a Free Intial Consult
Today's Date

MonthDayYear
Date
This appointment is for:*

Free New Client Initial Consult
Would you like to be added to our mailing list?*

YesNo
This appointment is for:*

MyselfSomeone else
Patient's Name*

First NameLast Name
Patient's Date of Birth*

MonthDayYear
Date
This person is:*
What is Your Name?*

Your First Name:Your Last Name:
What is Your Email?*
example@example.com
Your Phone Number Which Can Receive Texts:*
Best number to reach you during business hours (we will not contact you other than for appointment reminders or to answer your questions):
Zip Code:
In which of our offices would you like to receive our services?*

ModestoSan JoseSan Ramon
TMS requires multiple office visits. Other services can be provided remotely after one or two in-office appointments. Let's determine your travel time. Please type your ZIP code and PRESS ENTER:*
TMS requires multiple office visits. Other services can be provided remotely after one or two in-office appointments. Let's determine your travel time. Please enter your ZIP code and press Enter:*
TMS requires multiple office visits. Other services can be provided remotely after one or two in-office appointments. Let's determine your travel time. Please enter your ZIP code and press Enter:*
You are outside our free appointment service area. We offer a 25-minute paid consultation for $195, credited towards any services you use within 1 year. Would you like to book a 25-minute consultation for $195?

YesNo
Would you like to be added to our mailing list?*

YesNo
Thank you for your interest. Click here to clear your data.
Age (Don't Show)
I am interested in finding out more about:*

I am not sureFunctional qEEG Brain MappingTMSNeurofeedbackAuditory TrainingtDCSNear Infrared Light TherapyFocused Ultra-Sound TherapyFull Diagnostic EvaluationOther
My challenges are:*

DepressionAnxietyOCDADHDAutismAsperger’sAuditory Processing DisorderDyslexiaLearning DisorderDevelopmental DelaysAddictionBrain Injury / Brain FogPostconcussive Syndrome (PCS)Chronic PainInsomnia- Sleep-Related IssuesMemoryPTSDTinnitusOther
Have you taken any medications for depression?*

YesNo
Select any of these medications you have used in the past or are now taking.*

Celexa/CitalopramCymbalta/DuloxetineEffexor/VenlafaxineElavil/AmitriptylineFetzimaLexapro/EscitalopramLuvox/FluvoxamineNardil /PhenelzineNorpramin/DesipraminePamelor/NortriptylineParnate/TranylcyprominePaxil/ParoxetinePristiq/DesvenlafaxineProzac/FluoxetineRemeron/MirtazapineTofranil/ImipramineTrintellixViibryd/VilazodoneVivactil/ProtriptylineWellbutrin/BupropionZoloft/SertralineOther
Calculation of how many antidepressants taken
Who is your insurance provider?*

Aetna (In-Network)Anthem (In-Network)Availity (In-Network)Beacon - Carelon (In-Network)Blue Cross(In-Network)Blue Shield (In-Network)Carelon (In-Network)Cigna - Evernorth (In-Network)Evernorth (In-Network)Healthnet (In-Network)Humana (In-Network)Kaiser (Available in Modesto Area Only)MHN (In-Network)Magellan (In-Network)Medi-Cal (Only in Santa Clara & Stanislaus County)MedicareOptum (In-Network)Tri-Care (In-Network)Tri-West (In-Network)United (In-Network)UninsuredOther
Check insurance coverage for these services?*

YesNo
We don't accept Medicare, which extends treatment to almost 8 weeks and doesn't cover qEEG Brain Mapping for customized and targeted treatment. However, we offer Medicare patients a reduced option for $4,995.00. This includes 36 TMS sessions and the Brain Mapping, with the added advantage of completing the program in just 2.5 weeks. Would you be interested in proceeding with this option?*

YesNo
Would you like to be added to our mailing list?*

YesNo
Thank you for your interest. Click here to clear your data.
Kaiser coverage is limited to Modesto/Turlock/Merced area. Do you within with area?*

YesNo
Sorry, we can NOT accept your insurance. To qualify, you must meet the following criteria:

1) You are diagnosed with Major Depression.

2) You have tried two or more antidepressants.

3) You have engaged in some talk therapy.

4) You want TMS to treat your depression.

(These are your insurance company's requirements)

We offer a self-pay option for patients 4 years and older.
Would you like to proceed on a self-pay basis? We will provide a detailed, itemized receipt.*

YesNo
Would you like to be added to our mailing list?*

YesNo
Thank you for your interest. Click here to clear your data.
Good news! Your plan may cover depression treatment using TMS. Would you like to schedule your free consultation appointment now?*

YesNo
Would you like to be added to our mailing list?*

YesNo
Thank you for your interest. Click here to clear your data.
Here are the starting costs for some of our services:

1) Functional qEEG Brain Mapping: $2,995

2) TMS 20 Sessions (Functional qEEG Brain Mapping Included): $6,995

3) Medicare Patients:36 TMS Sessions (Functional qEEG Brain Mapping Included): $4,995

4) Neurofeedback 20 Hours (Functional qEEG Brain Mapping Included): $3,995

5) Auditory Integration Training 30 Hours (Testing Before and After Included): $3,995
After reviewing the cost of our services, would you still like to proceed?*

YesNo
Would you like to be added to our mailing list?*

YesNo
Thank you for your interest. Click here to clear your data.
Here are XX the starting costs for some of our services: 1) Functional qEEG Brain Mapping: $2,995 2) TMS 20 Sessions (Functional qEEG Brain Mapping Included): $6,995 3) Medicare Patients:36 TMS Sessions (Functional qEEG Brain Mapping Included): $4,995 4) Neurofeedback 20 Hours (Functional qEEG Brain Mapping Included): $3,995 5) Auditory Integration Training 30 Hours (Testing Before and After Included): $3,995*

YesNo
How did you hear about us?*

Doctor ReferralGoogle/Search EngineFamily/FriendFacebook or other Social MediaOther
Thank you for your interest. Check back soon, as conditions do change quickly. Please press SUBMIT and you will be added to our mailing list.
Website Source
Anything more you care to share?

0/150
Select date and time for your consult:*
Should be Empty:

Appointment Request - Insurance Check