Psychological And Neuropsychological Assessment Supplemental Form (Page 2 of 2) in pdf

Why is this assessment necessary at this time?

☐ C ontribute necessary clinical information for differential diagnosis including but not limited to assessment of the severity and pervasiveness of

symptoms; and ruling out potential comorbidities.

☐ Results will help formulate or reformulate a comprehensive and optimally effective treatment plan.

☐ Assessment of treatment response or progress when the therapeutic response is significantly different than expected.

☐ Evaluation of a member’s functional capability to participate in health care treatment.

☐ Determine the clinical and functional significance of brain abnormality.

☐ Dangerousness Assessment.

☐ Assess mood and personality characteristics impact experience or perception of pain.

☐ O ther (describe):

Has a standard clinical evaluation been completed in the past 12 months? ☐ Y ☐ N

If yes, when and by whom?

If no, explain why a standard clinical evaluation cannot answer the assessment questions.

Date of last known assessment of this type:

☐ No prior testing

If testing in past year, why are these services necessary now?

☐ Unexpected change in symptoms

☐ Previous assessment is likely invalid

☐ Evaluate response to treatment

☐ Other (specify):

☐ Assess function

Are units requested for the primary purpose of differentiating between medical, psychiatric conditions, and/or learning disorders and/or guiding

health care services? ☐ Y ☐ N

Are the units requested for the primary purpose of determining special needs educational programs? ☐ Y ☐ N

Are the units requested to answer questions of law under a court order? ☐ Y ☐ N

What are the patient’s currently known symptoms and functional impairments that warrant this assessment?

RELEVANT MENTAL HEALTH/SA HISTORY

Relevant Mental Health History:

☐ None

Is substance abuse/dependence suspected? ☐ Y ☐ N

If yes, how many day of sobriety?

Are medication effects a likely and primary cause of the impairment being assessed ☐ Y ☐ N

If yes, is this assessment necessary to evaluate the impact of medication on cognitive impairment and inform clinical planning accordingly ☐ Y ☐ N

If no, explain why testing is necessary.

If the primary diagnosis is ADHD, indicate why the evaluation is not routine:

☐ Previous treatment(s) have failed and testing is required to reformulate the treatment plan

☐ A conclusive diagnosis was not determined by a standard examination and/or

☐ Specific deficits related to or co-existing with ADHD need to be further evaluated

Other:

Signature of requesting clinician:

Providers may attach any additional data relevant to medical necessity criteria.

Massachusetts Collaborative — Psychological and Neuropsychological Assessment Supplemental Form

January 2015

Psychological And Neuropsychological Assessment Supplemental Form Page 2