Psychological And Neuropsychological Assessment Supplemental Form

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PSYCHOLOGICAL AND NEUROPSYCHOLOGICAL
ASSESSMENT SUPPLEMENTAL FORM
Provide specific information in context of each health plan’s unique medical
necessity criteria which are available on each plan’s website or by request.
IDENTIFYING INFORMATION
Dates of Service Requested: Start:
/
/
End:
/
/
First Name:
Last Name:
MI:
Date of Birth (MM/DD/YYYY):
Gender: ☐  Male ☐  Female Other:
Policy Number:
Health Plan:
Date Form Submitted:
Servicing Clinician:
Facility:
Phone Number:
NPI/TIN#:
Name and Role of Referring Individual:
☐  Self Referred
Contact Person:
Best Time to Contact:
Phone Number:
Fax:
Email:
Requesting Clinician/Facility (only if different than service provider):
Phone Number:
NPI/TIN#:
Contact Person:
Best Time to Contact:
Phone Number:
Fax:
Email:
RELEVANT DIAGNOSTIC DATA
Primary possible diagnosis which is the focus of this assessment?
Possible comorbid or alternative diagnoses:
☐  None
List all other relevant medical/neurological or psychiatric conditions suspected or confirmed:
☐  None
Relevant results of imaging or other diagnostic procedures (provide dates for each):
☐  None
ASSESSMENT PLAN AND HISTORY
Total hours of authorization for testing:
Psychological Testing:
Neuropsychological Testing:
Neuro-Behavioral Evaluation:
96101 =
96118 =
96116 =
96102 =
96119 =
(Note: Preauthorization not required by most plans)
96103 =
96120 =
List Likely Tests:
What suspected or confirmed factors suggest that assessment may require more time relative to test standardization samples?
☐  Depressed mood
☐  Physical symptoms or conditions such as:
☐  Low frustration tolerance
☐  Vegetative symptom
☐  Performance anxiety
☐  Grapho-motor deficits
☐  Receptive communication difficulties
☐  Suspected processing speed deficits
☐  Other:
1
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Massachusetts Collaborative — Psychological and Neuropsychological Assessment Supplemental Form
January 2015

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