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 Group*Previous Testing*NoYesIf yes, when*Provider InformationPsychologist Name* First Last Psychologist License #Group/Practice Name*Office Location*Email* Phone Number*Fax Number*Current 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 List test(s) requested and time required. Note: time required for each test should include administration, scoring and interpretation and brief write-up.1. Test Name*Time Required*2. Test NameTime Required*Test 2 Time3. Test NameTime Required*Test 3 Time4. Test NameTime Required*Test 4 Time5. Test NameTime Required*Test 5 TimeComments / Additional TestingIs the patient or legal guardian in agreement with the administration of these tests?*YesNo
