NEUROPSYCHOLOGICAL TESTING AUTHORIZATION REQUEST FORM
Please print clearly – incomplete or illegible forms will delay processing.
PATIENT INFORMATION
Name: _____________________________________________________
Date of Birth: ________________________________________________
Social Security #: ____________________________________________
Health Plan Name: ___________________________________________
PROVIDER INFORMATION
Provider Name: ___________________________________________
Group Name: ______________________________________________
Provider Tax ID #: _______________ NPI #: ______________________
Fax #: ________________________ Phone #: ___________________
MEDICAL INFORMATION
History of medical condition, trauma, or substance use disorder that may have neuropsychological consequences to the patient:
Patient’s cognitive symptoms/issues:
Date_____________________________________________________
History of previous treatments for the above symptoms:
Will this testing all or in part be used for educational/vocational remediation? Yes No
If yes, please explain:
How will understanding the neuropsychological status of this patient affect the treatment plan?
What are the patient’s diagnostic rule outs/referral questions?
SUBMIT TO
Utilization Management Department
Phone: 1-855-766-1497 Fax: 1-877-725-7751
ALLWELL FROM ABSOLUTE TOTAL CARE | PAGE 1
Patient’s psychiatric symptoms/issues:
MANeuroTestAuth_Approved_02192020
