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. To avoid delays, please submit this Request at least two (2) business days before the scheduled test date. To download and print a Psychological Testing Authorization click here. * indicates a required fieldPatient InformationPatient Name* First Last Social Security #* Date of Birth* MM slash DD slash YYYY Employer Group Previous Testing* No Yes If yes, when* Provider InformationPsychologist Name* First Last Psychologist License # Group/Practice Name Office Location* 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 Testing Note: 90791, 96116, 96121 do not require prior authorizationScheduled Date of Test* Month Day Year One (1) of each primary procedure code permittedPsychological Testing Primary Procedure (single 60-min unit) 96130 96131 (60 minute add-on) - Units Requested Neuropsychological Testing Primary Procedure (single 60-min unit) 96132 96133 (60 minute add-on) - Units Requested Administration & Scoring Primary Procedure (single 30-min unit) 96136 96137 (30 minute add-on) - Units Requested Administration & Scoring Primary Procedure by Technician (single 30-min unit) 96138 96139 (30 minute add-on) - Units Requested Please 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?* Yes No CAPTCHA Δ
