Referral Form - Unm Hospitals, University Of New Mexico printable pdf download

Center for Neuropsychological Services

•Department of Psychiatry•

MSC 09 5030•1 University of New Mexico•Albuquerque, NM 87131-0001

Phone (505) 272-8833•Fax (505) 272-8316

Center for Neuropsychological Services Provider Referral Form

1. Referring Provider Information: (for insurance purposes, licensed clinicians name, credentials and signature is required; ie. MD, Ph.D., etc)

Name: ___________________________________________________________________________________Credential:_____Telephone #:__________

Mailing Address: ________________________________________________________________________________________FAX #:_______________

Provider Signature: ______________________________________________________________________________________ Date: _______________

2. Patient Demographic Information:

Name: ___________________________________________________________________________Date of Birth: ____________ Age: ______Gender: _____

Mailing Address: _________________________________________________________________________________________________________________

Best phone for contacting: _______________ Cell___ Home___ Work ___

3. Primary language spoken by patient/family: _____________________________________________________________

4. Emergency Contact Information:

(if patient is a minor child please give parent/guardian information)

Telephone #:____________________

Name/Relationship: ________________________________________________________________________

Insurance Information:(include card copy front & back if possible)

ID. #: ________________

Policy Holder Name (if not patient): ________________________Date of Birth: ______________

Group #______________

Insurance Co. Name: __________________________________________________________ Insurance Co. Phone #: ______________

Claims mailing Address: ________________________________________________________________________________

6. Reason for Request:

Medical justification for request, pertinent background information ie. Medical history, (if necessary attach a separate sheet or

copy of office record): _____________________________________________________________________________________________________________

a. Medical/Psychiatric Diagnosis/History

___

none

___Brain Tumor

___ Cerebral Palsy

___ Pulmonary Disease

___ Seizures

___Cancer

___Obesity

___Kidney Disease

___Parkinson’s Disease

___Meningitis/Encephalitis

___Stroke

___Malnutrition

___Head Trauma

___Hypertension

___Toxic Exposure

___Metabolic Disorder

___Traumatic Brain Injury

___Diabetes

___TIA

___Headaches

___Developmental Delays

___High Cholesterol

___Thyroid Disorder

___Lupus

___Genetic Disorder

___Cardiovascular Disease

___HIV/AIDS

___Multiple Sclerosis

___Learning Disorder

___Arteriosclerosis

___Liver Disease

___Other:___________________________________

b. Diagnostic Clarification

___

Neurocognitive Disorder

___Mild Cognitive Impairment (MCI)

___ADHD

___Intellectual Disorder

___Dementia/Alzheimer’s

___Autistic Disorder/Asperger’s Disorder

___Language/Communication Disorder

___Competency

___Dyslexia/Reading Disorder

___Traumatic Brain Injury

___Presurgical Epilepsy

___Math Disorder

___Tourette’s Disorder/Tic Disorder

___Postsurgical Epilepsy

___Written Language Disorder

___Presurgical DBS

___ Other: _________________________________________________________________________________

c. Cognitive Concerns

___none

___ Information processing problems

___Dementia

___Memory problems

___Communication/Language Problems

___Baseline neuropsychological assessment

___Attention problems

___Change/Decline in Cognition/Thinking

___Cognitive Strengths/Weaknesses

___Other: ______________________________________________________________________________________________________________________

d. Behavioral/Emotional Concerns

___ none

___ Hyperactivity

___Noncompliance

___Depression

___ Substance abuse

___ Attention span

___Impulsivity

___Poor peer relations

___Suicidal ideation

___Anxiety

___Distractibility

___Poor anger control

___Hallucinations

___Homicidal ideation

___Other:_______________________________________________________________________________________________________________________

e. Treatment Planning

(Please describe how neuropsychological evaluation will help in treatment planning)

7. Additional records

(Please provide any additional information that you believe would assist us in providing the best care for your

patient, including: Medical records, school/special education records, neuroimaging reports, EEG/Video EEG reports, prior

neuropsychological/psychoeducational reports)

Referrals are reviewed for medical necessity by a clinical neuropsychologist. Failure to provide requested information may result in a delay

of services and/or scheduling of your patient. Appointments are scheduled as requests are received.

Referral Form - Unm Hospitals, University Of New Mexico

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