Fillable PSYCHOLOGICAL OR NEUROPSYCH TESTING AUTHORIZATION REQUEST FORM (Absolute Total Care)

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PSYCHOLOGICAL OR NEUROPSYCH TESTING AUTHORIZATION REQUEST FORM (Absolute Total Care)

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  • 24 check-boxes
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PSYCHOLOGICAL OR NEUROPSYCH TESTING AUTHORIZATION REQUEST FORM
Please print clearly – incomplete or illegible forms will delay processing.
PATIENT INFORMATION
Name: ___________________________________________________________
Date of Birth:______________________________________________________
Member ID #: _____________________________________________________
Social Security #: __________________________________________________
Health Plan Name: ________________________________________________
Referral Source: __________________________________________________
PROVIDER INFORMATION
Provider/Agency Group Name: ________________________________
Professional Credentials: ____________________________________
Provider Tax ID#: __________________________________________
Provider NPI/Sub Provider #: _________________________________
Address: _________________________________________________
Phone #: ____________________ Fax #: _______________________
CURRENT ICD DIAGNOSIS
The provider must report all diagnoses being considered for this patient.
*Primary
:
___________________________________________ R/O
:
__________________________________________ R/O
: ________________
Secondary
:
______________________________________________________________________________________________________________
Tertiary
:
_________________________________________________________________________________________________________________
Additional
:
_______________________________________________________________________________________________________________
Additional
:
_______________________________________________________________________________________________________________
Danger to self or others (If yes, please explain)? Yes No ___________________________________________________________________
________________________________________________________________________________________________________________________
MSE within normal limits (If no, please explain)? Yes No ___________________________________________________________________
________________________________________________________________________________________________________________________
WHAT ARE THE CURRENT SYMPTOMS PROMPTING THE REQUEST FOR TESTING?
Please indicate which level of care the member is currently engaged: _________ Inpatient _________ Outpatient
Anxiety
Depression
Withdrawn/poor social interaction
Mood instability
Psychosis/Hallucinations
Bizarre Behavior
Unprovoked agitation/aggression
Other _____________________
______________________________
______________________________
Self-injurious Behavior
Eating disorder symptoms: ________________________
Poor academic performance
Behavior problems at home
Behavior problems at school
Inattention
Hyperactivity
What is the question to be answered by testing that cannot be determined by a diagnostic interview, review of psychological/psychiatric records
or collateral information? How will testing affect the care and treatment in a meaningful way?
Have any questions?
Call us at 1-855-735-4398
mmp.absolutetotalcare.com
MMPPsychNeuroAuth_Approved_02192020
SUBMIT TO:
Utilization Management Department
PHONE 1-855-735-4398 FAX 1-877-725-7751
HISTORY
Does the patient have any signicant medical illnesses, history of developmental problems, head injuries, or seizures in the past?
Yes No Comments: ___________________________________________________________________________________________
Does the patient have a family history of psychiatric disorders, behavior problems, or substance use?
Yes No Uncertain Comments: _____________________________________________________________________________
Is there any known or suspected history of physical or sexual abuse or neglect? _______________________________________________________
Yes No Uncertain Comments: _____________________________________________________________________________
If ADHD is a diagnostic rule out, please complete the following: Is the patient’s presentation on intake consistent with ADHD?
Yes No
Indicate the results of Conner’s or similar ADHD rating scales, if given:
Positive Negative Inconclusive N/A
If the patient is a child, please indicate the collateral information you have obtained from the school regarding cognitive/academic functioning (i.e., teach-
er feedback, results of school standardized testing)?
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
Date of Diagnostic Interview: _________________________________________________________________________________________________
Has the patient had a Psychiatric Evaluation? Yes No If yes, date? _________________________________________________________
Basic Focus and Results: ____________________________________________________________________________________________________
REQUEST FOR AUTHORIZATION
Please check only one code:
Psych Testing
_________________________________________________________________
NeuroPsych Testing
____________________________________________________________
Please list the tests planned to answer the clinical questions.
1. _______________________________________________________________________________
2. _______________________________________________________________________________
3. _______________________________________________________________________________
4. _______________________________________________________________________________
5. _______________________________________________________________________________
6. _______________________________________________________________________________
Number of units requested to complete tests: _____________________________________________
Clinician Signature: ______________________________ Date: _____________ Clinician Signature: ____________________________________ Date: _________________
Clinician Name: __________________________________________________________ Clinician Name: _________________________________________________________________
Prescriber: Psychiatrist General Practitioner Other
CURRENT PSYCHOTROPIC MEDICATIONS
MEDICATION
DATE STARTED
COMPLIANT? (Y/N)
STANDARD REVIEW:
Standard 14-day time frame will
be applied.
EXPEDITED REVIEW: By signing below, I certify that applying the standard
14-day time frame could seriously jeopardize the member’s health, life, or
ability to regain maximum function.
SUBMIT TO
Utilization Management Department
12515-8 Research Blvd., Suite 400
Austin, Texas 78759
Phone: 1-855-735-4398 Fax: 1-877-725-7751
Have any questions?
Call us at 1-855-735-4398 mmp.absolutetotalcare.com
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PSYCHOLOGICAL OR NEUROPSYCH TESTING AUTHORIZATION REQUEST FORM (Absolute Total Care)

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Completed 5 May 2021

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