Fillable PSYCHOLOGICAL TESTING PRE-AUTHORIZATION REQUEST FORM (CalOptima)

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PSYCHOLOGICAL TESTING PRE-AUTHORIZATION REQUEST FORM (CalOptima)

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PSYCHOLOGICAL TESTING PRE-AUTHORIZATION REQUEST FORM
Page 1 of 2 12/20/18 v.1
All psychological testing requests must be pre-authorized using this form. Testing should not be administered until the
requested authorization is approved. All sections of the form must be completed in order to process the testing request.
Requests for testing should be made only after an initial assessment has been conducted. The initial assessment typically includes
clinical interviews, relevant history, a review of prior evaluations and testing, coordination/consultation with current/previous
providers, and coordination/consultation with the member’s school personnel (if applicable). Please note that psychological testing
requests for purposes of educational and/or legal reasons is not a covered benefit.
1. Mem
ber information:
Me
mber’s name:
Me
mber’s CIN:
Member’s DOB:
2. Pers
on/agency requesting you to administer psychological testing (specify name):
Psychiatrist: Court:
Psychotherapist: School staff (specify):
CalOptima: PCP/medical specialist:
Member/parent: Other:
3.
Phone:
Fax:
Testing pro
vider information:
Provider Name:
Provider Licensure/Discipline:
Name of Agency/Org:
Email:
4. DSM-5 di
agnosis:
Da
te initial assessment completed:
Code: Description:
Current Provisional
Code:
De
scription:
Current Provisional
Code: Description: Current Provisional
5. Wh
at is the clinical question(s) that psychological testing will answer? (Please be specific)
6. Ca
n the question (#5) be answered through other means (a diagnostic interview, a medical and/or neurological consult,
review of psychological/psychiatric records, or second opinion)?
Yes No. Please explain:
7. What are the current symptoms and/or impairments?
PSYCHOLOGICAL TESTING PRE-AUTHORIZATION REQUEST FORM
Page 2 of 2 12/20/18 v.1
8. How will the results of psychological testing be used for the treatment plan? (Please be specific)
9. To whom will the testing results be sent?
10.
Yes No If yes, date of eval.
Yes No If yes, date of eval.
Yes No If yes, date of test
Mental health treatment:
A. Has the member been evaluated by a psychiatrist?
B.
Has the member been evaluated by a psychotherapist?
C. Has the member had previous psychological testing?
D. If yes to A, B, or C, have you coordinated with provider?
Yes No
Please indicate the results of the coordination:
11. Is the member engaged in active substance use, in withdrawal, or in recovery from chronic use?
Yes No
12.
YesWere ratin
g scales administered for ADHD? No
A. If Yes, results of the rating scale(s):
Positive Inconclusive Negative
B. Scales administered:
C. If member is a child an
d ADHD is a diagnostic rule out, indicate the information obtained from and coordination with
the school regarding cognitive/academic functioning (i.e., standardized testing results):
13. P
sychological tests requested:
Name of Test: Test Domain (i.
e. personality, cognitive, etc.): Time Requested (per test):
Total Number of Hours Requested:
14. Prov
ider completing request form:
Prin
t name of provider:
Sig
nature of provider:
Date:
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Completed 11 March 2021

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