Fillable REQUEST FOR PSYCHOLOGICAL TESTING PLEASE TYPE ALL INFORMATION. (Mercy Care)

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REQUEST FOR PSYCHOLOGICAL TESTING PLEASE TYPE ALL INFORMATION. (Mercy Care)

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REQUEST FOR PSYCHOLOGICAL TESTING
PLEASE TYPE ALL INFORMATION. NOTE THAT REQUEST WILL NOT BE ACCEPTED UNLESS COMPLETED IN DETAIL WITH
ALL SUPPORTING INFORMATION ATTACHED.
Type of Service Requested: Psychological Testing Neuropsychological Testing
Psychosexual Testing (See bottom of last page for potentially authorized CPT codes and units.)
Name: DOB: AHCCCS #:
Guardian: Parent:
DCS:
Other Members of Team: JPO
DDD DCS
Other
Treating Doctor/NP Name : Phone/Email:
Clinic: Phone/Email:
Case Manager: Phone/Email:
Requesting Clinician/Title: Phone/Email:
Current location of member: (i.e. inpatient, foster care, family, home)
Diagnosis including substance use /abuse/dependence: Please be detailed including developmental disability if applicable.
Axis I:
Axis II:
Axis III:
What is the clinical question to be answer by testing?
Is this meant to support custody evaluations, parenting assessments, or court ordered testing? Yes No
Is this testing for Educational or Vocational purposes? Yes No
What are the current symptoms and/or functional impairments related to testing question?
How would the results of testing affect the treatment plan (please be specific)?
Medical/Psychological Evaluation and Treatment
Has patient had a psychiatric diagnostic evaluation? Yes Date: No
Has patient had previous psychological testing?
Yes Date: No
Focus of prior evaluation:
If current request is ADHD related, indicate latest results of Conners’ or similar ADHD ratings scales (please attach):
Positive Inconclusive Negative N/A (not ADHD related or no administration of rating scales.
Is testing intended to diagnose Autism Spectrum disorders? Yes No
If Yes:
Attach detailed Psychiatric Evaluation which should include a review of records of pediatrician, PCP, school observations,
coordination, rating scales and any other testing completed.
Current Substance Use (please document all substance abuse within the last year):
Requesting Clinician Signature: ____________________________________________
_
Date:
Supervisor Name Signature: ________________________________________________ Date:
www.MercyCarePlan.com
Form Date: 03/22/2017
REQUEST FOR PSYCHOLOGICAL TESTING
Current Psychiatric Medication list with dosages and effect:
Name of Medication Dose Target Symptoms Effect/Duration of Trial/Compliance
THE FOLLOWING MUST BE COMPLETED BY PSYCHIATRIC PROVIDER OR MEDICAL DIRECTOR IF NOT ASSIGNED OR
ASSIGNED PROVIDER IS NOT AVAILABLE.
Detailed Clinical summary from treatment psychiatric provider for 6 months:
Clinical opinion and rationale (based on criteria) of psychiatric provider for testing request:
Printed Name of
Provider:
Phone: Email:
Signature of Provider:
________________________
_______________
Date:
Required Attachm
ents:
• BHMP Evaluation and progress notes that detail assessment of clinical concern listed above.
• Any supporting rating scales
• Neurological assessment, reviewed by BHMP if for a Neuropsychological Evaluation
• Any prior testing completed
Psychological testing: 96101-, 96102 -, 96103 -
Neuropsychological testing: 96116, 96118,
96119
Psychosexual testing: 96101, 96102, 96103
NPI#: Phone#:
Name of Identified Mercy Care Contracted Provider
Servicing Provider/Facility Information:
Servicing Provider Organization:
Address:
TIN#:
Administrative Contact Name:
Billing Address:
After this form is completed, please fax it to Mercy Care's Prior Authorization Department at 1-800-217-9345.
www.MercyCareAZ.org
Form Date: 07/1/2019
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REQUEST FOR PSYCHOLOGICAL TESTING PLEASE TYPE ALL INFORMATION. (Mercy Care)

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Completed 31 July 2021

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