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 a certification number is issued.

Clinician Information

Outpatient clinics please use same NPI for both fields.

Phone () -
Fax () -
Patient Information
Diagnosis

Please use the most up to date ICD codes. ICD codes can be three, six or seven characters.

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

Please type your full name in the signature box.