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The Fisher Wallace Stimulator Authorization Form 2014 - Shopify-2026

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The document is an authorization form for the Fisher Wallace Stimulator®, which is FDA-cleared for treating insomnia, anxiety, depression, and chronic pain. Patients need written authorization from a licensed healthcare practitioner to purchase the device. The form includes sections for practitioner and patient information, as well as details on insurance coverage for reimbursement when prescribed for chronic pain.

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Click ‘Get Form’ to open it in the editor.
Begin by filling out the Practitioner’s Information section. Enter the practitioner’s name, address, city, state, phone number, and state license number accurately.
Next, complete the Patient Information section. Provide the patient’s name, address, city, state, phone number, and zip code.
In the authorization statement, specify the patient's name and the treatment purpose clearly. Ensure that you include any relevant diagnosis codes as required.
Finally, have the practitioner sign the form electronically within our platform to validate the authorization before submitting it via fax or email.

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What is the difference between TMS and Fisher Wallace?

Fisher Wallace Is NOT TMS Therapy Both TMS therapy and Fisher Wallace Stimulators end goal is to stimulate the brain and cause neuromodulation. The similarities end there. Fisher Wallace Stimulator is NOT a TMS device. Instead, it is a tACS device.

Who should not use the Fisher Wallace stimulator?

- Do not use this product if you have known or suspected heart disease. - Do not use this product if you have known or suspected trigeminal neuralgia. - Do not use this product if you are pregnant. - Do not use this product if you have reacted poorly to the idea of electrical stimulation of any kind.

What does the Fisher Wallace stimulator do?

The Fisher Wallace stimulator works by stimulating the brains production of serotonin, , and other neurotransmitters. The device uses a precise frequency of alternating current and voltage to increase blood flow to the brain and enhance neuronal activity.

How much does the Fisher Wallace stimulator cost?

How much do they cost? The Fisher Wallace Stimulator costs $699, discounted to $599 for Medicaid, Medicare, veterans, and first responders (police, fire, EMT, etc.). The Alpha-Stim AID (for anxiety, depression, insomnia) costs $795; and the Alpha-Stim M (for acute, chronic, and post-traumatic pain) device is $1,195.

What is Fisher Wallace stimulator?

Similar to other at-home brain stimulation devices, the Fisher Wallace Stimulator uses a gentle electric current, rather than magnetic energy, to stimulate serotonin production and invigorate activity in the brain region responsible for mood regulation.

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