VNS Therapy Patient Eligibility, Education and Authorization Form: Fill out & sign online

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Click ‘Get Form’ to open the VNS Therapy Patient Eligibility, Education and Authorization Form in the editor.
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.
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.
Indicate the principal diagnosis by checking one of the provided options that best describes the patient's condition. If applicable, describe any other diagnosis in the space provided.
Complete the insurance information section by indicating whether a patient face sheet is attached. Fill in details for primary and secondary insurers as required.
Review and sign where indicated. The physician must sign to authorize information release, while a patient or legal guardian signature is required for PHI disclosure.

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Who is a candidate for VNS?

Vagus nerve stimulation (VNS), a type of neuromodulation, may be recommended to treat epilepsy if your seizures are not controlled by medications and you are not a candidate for other types of epilepsy surgery. VNS is FDA-approved for adults and children as young as four years old.

Who qualifies for a VNS?

You may be a good candidate for VNS if you have epilepsy that is not adequately controlled with at least two different anti-seizure medications (age four and older). For depression, you may be eligible if your symptoms have not had an adequate response to four or more antidepressant medications (age 18 and older).

Does VNS need to be turned off for MRI?

Does the device need to be turned off before my patient gets an MRI? Yes. Prior to getting an MRI, turn device stimulation OFF by programing all output currents to 0.0 mA for all therapy modes: Normal Output Current (mA): 0.0.

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