VNS Therapy
VNS (vagus nerve stimulation) Therapy is a unique treatment approach now available specifically for treatment-resistant depression. VNS Therapy is indicated for use as an adjunctive long-term treatment of chronic or recurrent depression for patients 18 years of age or older who are experiencing a major depressive episode and have not had an adequate response to four or more adequate antidepressant treatments.
What is VNS Therapy?
VNS Therapy has been shown to provide significant quality of life improvements. Benefits include increased energy, improved relationships with friends and family members, and better ability to function at work and in daily activities.1 Adding VNS Therapy has been shown to succeed when other antidepressant treatments have not worked or have stopped working. The effectiveness of VNS Therapy improves over time and last long term.2
Getting Treatment
Sometimes medications alone do not adequately relieve depression, or they relieve depression for a period of time, but then stop working. If multiple treatments, including psychotherapy, have not adequately or continuously relieved your depression, it may be time to discuss VNS Therapy with your psychiatrist as a long-term treatment option.
The first step
To determine whether your insurance covers VNS Therapy, click the VNS Screening button above and submit the form online or you may pick up a copy of the form at our office.
FREE VNS Therapy Screening Form
Please answer all the questions in this section
Note: This page is on a secure server and the information will be encrypted before being sent of the Internet to our office, because we value your privacy and vigorously guard all confidential information.
The following information is optional.
If you provide this information (and if you qualify), it will be used to contact your insurance company on your behalf and ask them to provide benefits to cover VNS Therapy for you.
Referring physician (if any)
Name:
Address:
City:
State:
ZIP:
Phone:
About you
Address:
City:
State:
ZIP:
Phone:
Date of birth:
Gender:
SSN:
Insurance information
Primary Insurer
Secondary Insurer
Name of company:
Phone number:
Name of insured:
Employer/Plan Name:
Policy Number:
Group Number:
Click the button at the bottom of this page to have this information screened for eligibility and submitted to your insurers:
Leave this box checked if you agree to the terms and conditions (see below)
Terms and Conditions
By submitting this information you agree to the following:
I authorize ths release of the above information to the above-named insurers and Cyberonics, Inc. (makers of VNS device)
You authorize Richard N. Rubinstein, M.D., P.C. to provide the above Protected Health Information (PHI) to the above-named third party payors and to Cyberonics, Inc., the makers of the electronic VNS Therapy device. The information will be kept confidential in accordance with HIPPA guidelines and will be used only to assess your eligibility to receive VNS Therapy and to attempt to obtain insurance benefits on your behalf to cover VNS Therapy and related health care services and to communicate those findings back to you.
You further authorize Cyberonics, Inc. to contact you directly and/or collaborate with Dr. Rubinstein and his staff on your behalf for the purpose of making certain that you make a well-informed decision regarding VNS Therapy, to verify your insurance, seek prior authorize as necessary for VNS Therapy related procedures. They may directly contact you for educational purposes.
You understand that the records to be disclosed to Cyberonics include insurance information as well as your name, address, phone number, diagnostic information, and medical history. You further understand that the records used and disclosed pursuant to this authorization may include information relating to Human Immunodeficiency Virus ("HIV") infection or Acquired ImmunoDeficiency Syndrome ("AIDS"); treatment for -- or history of -- drug or alcohol dependence or abuse; or mental or behavioral health or psychiatric care. You further understand that to the extent that any recipient of this PHI is not a "covered entity" under Federal or State privacy law, the information may no longer be protected by Federal or State privacy law once it is disclosed to the recipient and ,therefore, may be subject to re-disclosure by the recipient.
You understand that you may revoke this authorization in writing at any time except to the extent that Dr. Rubinstein has relied upon the authorization) by sending or faxing a written notice of revocation to Dr. Rubinstein by certified mail.
You understand that this authorization, unless sooner revoked, will expire five years from the date you submit it.
Finally, you understand that you can choose to omit your insurance information and submit only the answers to questions 1 through 10 plus your name and telephone number, in which case no effort would be made to determine your eligibility for benefits and your information would be screened only to determine whether you would be likely to benefit from VNS Therapy.
