Fillable Request For Psychological Or Neuropsychological Testing printable pdf download

Reset Form

Please fax form to CommunityCare Behavioral Health Services (CCBHS) at 918-879-4316 or 800-213-2956.

Questions? Call 918-594-5262 opt 1 or 800-774-2677 opt 1.

Request for Psychological or Neuropsychological Testing

Patient Name: ________________________________________________________________________________________________

DOB: _______/______/______

Member ID#:__________________________________ Date of Request: ______/_____/______

Provider Performing Testing: ________________________________________________Specialty:___________________________

Contact person: ______________________________ Telephone#:__________________________ Fax#:_____________________

Who referred Member for testing: Name___________________________________________ Specialty: _______________________

PLEASE KEEP IN MIND THAT TESTING MUST BE PRE-AUTHORIZED OR PRE-CERTIFIED.

EVALUATIONS OTHER THAN FOR DIAGNOSING OR TREATING A MEDICAL OR MENTAL HEALTH

CONDITION AND EDUCATION EVALUATIONS ARE SPECIFICALLY EXCLUDED.

Reason for Testing Request:

Please provide information that supports the need for psychological testing vs. a thorough psychological or psychiatric

evaluation/interview to assist in diagnosing a psychiatric disorder or evaluating the need for a change in treatment plans: ___________

____________________________________________________________________________________________________________

2. Has the member had a previous evaluation (90791 or 90792)?  Yes

 No If yes, when and what were the results? _________

____________________________________________________________________________________________________________

3. Has the member had previous treatment for this condition?  Yes  No If yes, what was the outcome?____________________

____________________________________________________________________________________________________________

4. Please list the names of the tests requested. Attach an additional sheet if necessary to ensure legibility. ______________________

____________________________________________________________________________________________________________

5. Is the member on medication?  Yes

 No

Have the side effects been ruled out?  Yes

 No

Please list medications: ________________________________________________________________________________________

____________________________________________________________________________________________________________

6. Please add any other details you feel would be relevant for this request: ________________________________________________

____________________________________________________________________________________________________________

 I am requesting

hours of 96101 (Psych-Testing)

 I am requesting

hours of 96102 (Psych-Testing)

 I am requesting _________ hours of 96118 (Neuropsych Testing)

 I am requesting _________ hours of 96119 (Neuropsych Testing)

Note: Please include any additional clinical information to support this request. If services are authorized, the certification will

begin on the standard business day complete clinical information is received.

Revised 01/2016

Request For Psychological Or Neuropsychological Testing