Form 004 by Chase | 29 Sep, 2024 M&B Form 004 - Preauthorization Updated 03-SEP-2024 Use this form to preauthorize appointment fees up to 6 days before your appointment date.Name(Required) First Last Email(Required) HiddenNew Patient or Existing Patient? New Existing New patients include those that have not completed the intake and first and second psychiatrist appointments.New Patient Appointments(Required) Intake Appointment First Psychiatrist Appointment Second Psychiatrist Appointment Appointment Fee(Required) Intake Appointment First Psychiatrist Appointment Second Psychiatrist Appointment Standard Appointment Extended Appointment Long Appointment TMS Maintenance Did Not Attend Intake Appointment Price: First Psychiatrist Appointment Price: Second Psychiatrist Appointment Price: Travel Letter Price: Script Price: Standard Appointment Price: Extended Appointment Price: Long Appointment Price: TMS Maintenance Price: Did Not Attend Price: Date of appointment(Required) DD slash MM slash YYYY Preauthorization opens 6 days before the appointment date.Total Credit Card Terms and Conditions(Required) I agree to the Terms and Conditions.For emergency care or in a life threatening situation, call 000 or present to your nearest emergency department. Crisis support is also available through Lifeline on 13 11 14 or the Mental Health Emergency Response Line on 1300 555 788. Further useful information can be found at https://www.yourhealthinmind.org. Do not use this enquiry form in a crisis. Responses may take up to 5 business days. By submitting this form you agree to these conditions.