Psychological & Neuropsychological Testing Pre-Authorization Request Form - Minnesota - Bluelink

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Psychological & Neuropsychological Testing
Pre-Authorization Request Form
Fax form to (651) 662-0854
Member ID: _______ ____________________
Date of birth: ______________
Member name: _______________________________________________________________________
Member address: _____________________________________________________________________
City/state/zip: ________________________________________________________________________
Phone: _______________________
Contact person: ______________________________________________________________________
Phone: _______________________
Fax: _______________________
Clinic name: _____________________________________________ Clinic ID #: __________________
Individual provider ID/NPI number: __________________
Individual provider name: _________________________________ Degree/Lic: _________________
Provider address: _____________________________________________________________________
City/state/zip: _______________________________________________________________________
Have you completed a psychiatric/psychological diagnostic assessment (DA) with this patient? (In most cases
an initial diagnostic assessment must be completed before testing will be authorized)
Yes*
No
*If yes, please submit a copy of the evaluation with this form.
Date DA completed: ______________
Is the patient currently hospitalized?
Yes*
No
*If yes, is it medically necessary for testing to be done prior to discharge?
Yes
No
DSM or ICD diagnosis or rule out diagnosis:
Relevant medical conditions:
Psychosocial and environmental problems:
X18551R02 (02/14)
An independent licensee of the Blue Cross® and Blue Shield® Association serving residents and businesses of Minnesota.

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