933149 04/2020
Medicare Advantage
Behavioral Health Request for Psychological Testing
(Note: Form for psychological testing only. Neuropsychological testing is authorized by medical precertification, not Behavioral Health)
Provisional Diagnosis: (ICD 10 Code)
# Units/Days
Dates of Service
(if scheduled)
Tests Requested
List the name of all tests to be performed
(Add additional pages if more space is needed)
Today's Date:
Customer Name:
Customer ID #:
Date of Birth:
Fax:1.866.949.4846 500 Great Circle, Nashville, TN 37228 Tel:1.866.780.8546
Date of Initial Interview:
Results of initial diagnostic interview
What previous treatment has member
received, including medications?
What questions are to be answered by
the psychological testing?
Can the above information be obtained
through other means?
(Examples: clinical
assessment, records or medication review, or use
of prior evaluations)
How will the results of the testing be
used to guide treatment decisions?
Contact Information
Provider Name: NPI #:
Contact Person:
Please fax completed form to Behavioral Health Unit at 1.866.949.4846
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