home | contact us | survey | search

Psychological Testing Request

United Behavioral Health/US Behavioral Health Plan

Instructions: Please be aware the information you enter will not be saved if you accidentally close this window or lose your Internet connection. When you have completed the form, please use the "printable page" icon at the bottom of the page to make sure the page prints properly.

Required fields are yellow. Respond to all questions indicating N/A when the question does not apply to you. Attach additional pages where necessary, labeling each with the corresponding question.

Name of Member to Receive Testing(Last , First):		Member's DOB:	Subscribers's Insurance #:
Authorization Dates Requested: Start:                End:
Psychologist:	Degree:	Phone #:	Fax #:
Street Address:	City:	State: Select a state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming	Zip Code:
Type of Licensure:	Has the Diagnostic Interview (90801) taken place? Yes  No		Date Diagnostic Interview Completed (90801 falls under UBH Open Authorization):
Testing Referred to Requesting Psychologist By: Name/Degree/Specialty/Phone:
Background Information (include current Level of Care, relevant symptoms, treatment history, previous attempts to answer diagnostic questions including dates and types of previous psychological/ neuropsychological testing, psychotropic medications, risk factors, substance abuse issues, etc)
Purpose of Testing (referral question, different diagnostic issues to be addressed, contributions to clinical treatment plan)
Current and Provisional DSM-IV Diagnosis(es) If neuropsychological testing request, include applicable medical (Axis III) diagnosis(es) with ICD-9 code(s).
Rule Out Diagnosis(es)
List (Spell Out) All Tests Requested			Total Actual Testing Hours Requested(Do not include 90801,90806 or 90846. These codes are covered under UBH Open Authorization.) Total Testing Time Requested:
Psych Testing: 96101   96102   96103	Neuropsych Testing: 96118   96119   96120
Feedback Session Requested: Yes  No	If a feedback session is requested(90806/90846) please claim under UBH Open Authorization.
Post-Service Request?: Yes  No		Court Ordered?: Yes  No

printable page (Note:Please select printable page icon before printing to obtain correct page formatting.)

Reset (Note: This will reset all the values on the page.)

Security Notice    Privacy Policy    Site Use Agreement
Copyright © 2002-2008 United Behavioral Health and its subsidiary USBHPC