Psychological/Neuropsychological Testing Preauthorization Request Form

Instructions

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

Clinician Information

Outpatient clinics please use same NPI for both fields.

Phone () -
Fax () -
Patient Information
Diagnosis

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

Add
Months
Max characters: 200
Remove
Remove
Add
Remove
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Remove
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Referral Information
CPT Code Requested
Max characters: 75
Max characters: 2000

Please type your full name in the signature box.