VNS Therapy Eligibility and Education Form 2026

1. Click ‘Get Form’ to open the VNS Therapy Eligibility and Education Form in the editor.
2. Begin by filling out the 'Requesting Physician Information' section. Enter the physician's name, NPI number, phone number, and details for the surgeon including their name and NPI number.
3. In the 'Patient Information' section, provide the patient's first and last name, address, date of birth, and contact information. Ensure you select the appropriate sex option.
4. For the 'Principle Diagnosis', check one of the provided options that best describes the patient's condition. If applicable, describe any other diagnosis in the space provided.
5. Complete the insurance information section by indicating whether a patient face sheet is attached. Fill in details about primary and secondary insurers as required.
6. Review all entered information for accuracy before signing. The physician must sign and date at the bottom of the form to authorize release of information.

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