Psychological/Neuropsychological Testing Preauthorization Request Form

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Instructions

Only licensed psychologists or medical doctors can use this form. Fields marked with an asterisk are required. The certification is not valid until a certification number is issued.

Please check here if this testing is for Autism Spectrum Disorders

Clinician Information

Clinician's First Name

Clinician's Last Name

Clinician's NPI

Group's NPI

Outpatient clinics please use same NPI for both fields.

Phone Area Code () First Three Digits - Last Four Digits

Phone Extension

Fax Area Code () First Three Digits - Last Four Digits

Mailing Address 1

Address 2

ZIP Code

City

Patient Information

Patient's First Name

Patient's Last Name

Date of Birth

ID Card Number

Diagnosis

You must use ICD-10 codes. ICD-10 codes can be three, six or seven characters. Please ensure you use the correct codes.

Primary Psychiatric Diagnosis

Current Height

Current Weight

Weight Loss/Gain in lbs

Weight Loss/Gain in Last Months

Comments Regarding Medical Issues Related to Eating Disorders Max characters: 200

Primary Psychiatric Diagnosis 2 Remove

Primary Psychiatric Diagnosis 3 Remove

Rule out Diagnosis Add

Rule out Diagnosis 2 Remove

Rule out Diagnosis 3 Remove

Hidden

Hidden Remove

Hidden

Hidden Remove

Axis V

Medical Diagnosis

Axis V Current GAF

Referral Information

Source

Number of Testing Units Requested

CPT Code Requested

96116, 96121

96130, 96131

96132, 96133

96136, 96137

Other: Other Message

Date of Testing

If yes, explain: Max characters: 75

Specific reason for testing: List each test name and units per test along with functional limitations and clinical information. (what does the referral source want to know?) Max characters: 2000

Electronic Signature:

Please type your full name in the signature box.

Email Address:

Companion Benefit Alternatives, Inc.

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