[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-288916-105":53,"doc-detail-288916-en":127},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":120,"head_meta":122,"extra_data":124,"updated_unix":126},105,"en","esketaminespravato-request-form","ESKETAMINE/SPRAVATO REQUEST FORM","","Esketamine/Spravato Request Form collects required patient, provider, and authorization details for in-network and out-of-network processing. It captures membership information, clinician and site contacts, REMS certification status, diagnosis of Major Depressive Disorder, and relevant coding and clinical background. The form also records suicidality assessment elements within the prior 48 hours, medication dosing history, rating scales for inadequate response, augmenting agents, combination antidepressant plan, and safety and monitoring confirmations for administration and continued treatment.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/esketaminespravato-request-form/288916/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/esketaminespravato-request-form/288916.png","ImageObject",442,249,{"name":88,"@type":89},"Ophelia","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-07","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",6,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What information does the Esketamine/Spravato request form collect?","Question",{"text":109,"@type":110},"It collects member and provider details, clinician information, site contact data, REMS certification status, authorization and diagnosis information, and treatment details including medication dosing dates.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"How is Major Depressive Disorder and suicidality assessed on the form?",{"text":114,"@type":110},"The form asks whether the member has a diagnosis of Major Depressive Disorder and includes questions about confirmed suicide ideation with intent in the last 48 hours using an evidence-based suicide risk assessment tool.",{"name":116,"@type":107,"acceptedAnswer":117},"What treatment and safety elements must be documented for administration?",{"text":118,"@type":110},"It requires entries for medication dosing, rating scales for inadequate response, augmenting agents, combination with an oral antidepressant, and checkboxes confirming monitoring plans and that risks (sedation, dissociation, abuse/misuse, and increased suicidal thoughts/behavior) were discussed.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},288916,1790963419,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":9},7971461741311,"https://ap-avatar.wpscdn.com/avatar/74000253aff267980c6?x-image-process=image/resize,m_fixed,w_180,h_180&k=1779345379180704826","ESKETAMINE/SPRAVATO REQUEST FORM \n\n| In Network | | | Out of Network | | | | | | |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| Member Name: | | | | | | | | DOB: | |\n| Health Plan: | | | Member ID: | | | | | | |\n| Provider: | | | | | | | | Provider ID: | |\n| Group NPI: | | | Tax ID: | | | | | | |\n| Clinician: | | | Clinician NPI: | | | | | | |\n| Site Address: | | | | | | | | | |\n| Primary Contact: | | | Phone: | | | | | | |\n| Email: | | | Fax: | | | | | | |\n| Certified in Spravato REMS Program? | | Yes | No | | | | | | |\n| Authorization Information | | | | | | | | | |\n| Code (choose 1) | Start Date | | | | Units | | | | Frequency |\n| G2082 (up to 56mg)\u003Cbr> G2083 (greater than 56mg) | | | | | | | | | |\n| Clinical Information (Please attach any additional information necessary for review) | | | | | | | | | |\n| Member has diagnosis of Major Depressive Disorder? | | | | Yes | | | No | | |\n| Diagnosis Code | Diagnosis Description | | | | | | | | |\n| | | | | | | | | | |\n| | | | | | | | | | |\n| | | | | | | | | | |\n| Diagnosis made by: | | | | | | | | | |\n| MDD with Suicidality:\u003Cbr>Does the member have confirmed suicide ideation with intent in the last 48 hours based on an\u003Cbr>evidence-based suicide risk assessment tool? Yes No\u003Cbr>If yes, what evidence-based tool was used to make this assessment? \u003Cbr>If yes, will the 1st dose be administered in an inpatient setting? Yes No\u003Cbr>If yes, in the last 6 months, has the member had an active substance abuse disorder, opioid use disorder, or alcohol use disorder? Yes No | | | | | | | | | |\n\n\n| Medication | Dose | Start Date | End Date\u003Cbr>(note current if active) |\n| --- | --- | --- | --- |\n| 1. | | | |\n| Rating scale used to determine inadequate response: | | | |\n| 2. | | | |\n| Rating scale used to determine inadequate response: | | | |\n| 3. | | | |\n| 4. | | | |\n| 5. | | | |\n| 6. | | | |\n| Augmenting agents used: | | | |\n| Treatment to be used in combination with an oral antidepressant: Yes No\u003Cbr>Medication: Dose: | | | |\n| Please check all that apply:\u003Cbr> No history of aneurysmal vascular disease No history of arteriovenous malformation No history of intracranial hemorrhage\u003Cbr> Not currently pregnant and risks of pregnancy discussed with patient or caregiver, or pregnancy testing not indicated\u003Cbr> Not currently breastfeeding or risks of breastfeeding discussed with patient or caregiver\u003Cbr> Monitoring planned after each administration\u003Cbr> Risks of sedation and dissociation after administration discussed with patient or caregiver Risks of abuse and misuse discussed with patient or caregiver\u003Cbr> Risks of increased suicidal thoughts and behavior discussed with patient or caregiver | | | |\n| Continued Treatment (no response required for initial request):\u003Cbr> The condition has improved with treatment\u003Cbr>Rating scale used: Score: Date completed: The treatment has been manageable or no side effects reported | | | |","cbCaiaaugpOqezNf","https://ap.wps.com/l/cbCaiaaugpOqezNf","pdf",120632,"English","# Authorization Information\n## Clinical Information\n## Medication and Treatment Details\n## Continued Treatment","[{\"question\":\"What information does the Esketamine/Spravato request form collect?\",\"answer\":\"It collects member and provider details, clinician information, site contact data, REMS certification status, authorization and diagnosis information, and treatment details including medication dosing dates.\"},{\"question\":\"How is Major Depressive Disorder and suicidality assessed on the form?\",\"answer\":\"The form asks whether the member has a diagnosis of Major Depressive Disorder and includes questions about confirmed suicide ideation with intent in the last 48 hours using an evidence-based suicide risk assessment tool.\"},{\"question\":\"What treatment and safety elements must be documented for administration?\",\"answer\":\"It requires entries for medication dosing, rating scales for inadequate response, augmenting agents, combination with an oral antidepressant, and checkboxes confirming monitoring plans and that risks (sedation, dissociation, abuse/misuse, and increased suicidal thoughts/behavior) were discussed.\"}]","ESKETAMINE/SPRAVATO REQUEST FORM | PDF",1789634211]