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. * indicates a required fieldPatient InformationPatient Name* First Last Social Security #*Date of Birth* 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 TestingScheduled Date of Test* MM DD YYYY 1. Test Name*Psychological Testing Evaluation Codes (60 minute unit)96130/9613196132/96133 (Neuropsychological)Number of Units RequestedAdmin & Scoring Codes (30 minute unit)96136/9613796138/96139 (Technician)Number of Units Requested2. Test NamePsychological Testing Evaluation Codes (60 minute unit)96130/9613196132/96133 (Neuropsychological)Number of Units RequestedAdmin & Scoring Codes (30 minute unit)96136/9613796138/96139 (Technician)Number of Units Requested3. Test NamePsychological Testing Evaluation Codes (60 minute unit)96130/9613196132/96133 (Neuropsychological)Number of Units RequestedAdmin & Scoring Codes (30 minute unit)96136/9613796138/96139 (Neuropsychological)Number of Units Requested4. Test NamePsychological Testing Evaluation Codes (60 minute unit)96130/9613196132/96133 (Neuropsychological)Number of Units RequestedAdmin & Scoring Codes (30 minute unit)96136/9613796138/96139 (Technician)Number of Units RequestedNote: 90791, 96116, and 96121 do not require prior authorizationComments / Additional TestingIs the patient or legal guardian in agreement with the administration of these tests?*YesNo
