Psychological Or Neuropsychological Testing Request - Blue Cross Blue Shield Of Texas

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Psychological or Neuropsychological

TESTING REQUEST FORM

Provider must call BCBSTX at 800-528-7264 to verify benefits. To expedite the processing of your request, please complete all sections of the form.

For Inpatient Place of Service - Please fax at 972-239-7499.

For Outpatient Place of Service - Please fax to BCBSTX at 972-231-8118.

Request Submission Date: ______________________________ Requested Testing Start Date: _______________________________

Patient and Subscriber Information

Patient Name___________________________________________________

Date of Birth__________________________________________________

Subscriber Name________________________________________________

Subscriber ID #____________________ Group #______________________

c Medical Practitioner c BH Practitioner

Place of Service c Inpatient c Outpatient

Testing Provider Information

Licensure________________________ NPI#_____________________

Name __________________________________________________

City____________________________ State______ Zip_______________

Address_______________________________________________________

Phone #________________________ Fax #________________________

Email Address___________________________________________________

c Yes

c No

If requesting neuropsychological testing, are you a board certified neuro-psychologist?

Referral Information

Who referred the patient for testing? Name ______________________________________________________

Relationship to patient

_______________________________________________________

(i.e. PhD, PCP, Therapist, Medical Director, Parent, Psychiatrist, Teacher, School, etc.)

Assessment History

Have you met with the patient to complete a diagnostic evaluation? c Yes c No

Has a diagnostic evaluation been completed by another provider? c Yes c No

If yes, the diagnostic eval was completed by? Name __________________________________ Date____________________ License Type:_______________

Has the patient had previous psychological testing? c Yes, when?____________________ c No

c Not sure

Focus of Previous Testing: ______________________________________________________________________________________________

Current or Provisional Diagnosis

Current DX — Please include all DSM 5 and/or medical diagnoses that apply.

Code #: _______________________ DX Name: ________________________________ Specifier: _____________________________________

What clinical/referral question(s) need to be answered by testing that cannot be answered by a diagnostic interview, medical/neurological consult or review of medical records?

______________________________________________________________________________________________________________

What are the current symptoms and/or functional impairments related to the testing question(s)?

_______________________________________________________________________________

55693.0915