Pre-authorize Psychological Testing Authorizations online. Complete the Preauthorization of Psychological Testing form below to send a digital request directly to one of our Clinical Care Managers. Care Managers will call you to review your request. To download and print a Psychological Testing Authorization click here. * indicates a required fieldPatient InformationPatient Name* First Last Social Security #*Date of Birth* Date Format: MM slash DD slash YYYY Employer GroupPrevious Testing*NoYesIf yes, when*Provider InformationPsychologist Name* First Last Psychologist License #Group/Practice NameOffice Location*Phone Number*Fax NumberCurrent Diagnosis*Current Medications*Patient's Current Symptoms*Referral Question(s)*Please state the specific clinical questions you want the psychological testing to address.Please list all you have done to answer these questions prior to requesting the psychological testing.*How will testing aid the patient's care?*Requested Testing Note: 90791, 96116, 96121 do not require prior authorizationScheduled Date of Test* MM DD YYYY One (1) of each primary procedure code permittedPsychological Testing Primary Procedure (single 60-min unit) 96130 96131 (60 minute add-on) - Units RequestedNeuropsychological Testing Primary Procedure (single 60-min unit) 96132 96133 (60 minute add-on) - Units RequestedAdministration & Scoring Primary Procedure (single 30-min unit) 96136 96137 (30 minute add-on) - Units RequestedAdministration & Scoring Primary Procedure by Technician (single 30-min unit) 96138 96139 (30 minute add-on) - Units RequestedPlease list the name(s) of all psychological tests you intend to perform.Please list the name(s) of all neuropsychological tests you intend to perform.Comments:Is the patient or legal guardian in agreement with the administration of these tests?*YesNo
