Get Psychological/neuropsychological Testing Request Form - Tmhp.com

Filling out the Psychological/Neuropsychological Testing Request Form is an essential process for obtaining necessary evaluation services. This guide will provide you with clear and concise steps to effectively complete the form online.

Follow the steps to successfully fill out the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the identifying information. In the Client Information section, fill in the client’s name (last, first, middle initial), Medicaid number, date of birth, and age. Make sure all entries are accurate and up to date.
3. In the Provider Information section, provide the performing provider’s details including their name, telephone number, mailing address (including street address, suite number, city, state, and ZIP code), Medicaid Provider Identifier (ID), NPI, taxonomy, and benefit code.
4. Navigate to the Current DSM Diagnosis section. List all relevant diagnosis codes for the patient. Include information if the client has a current substance abuse problem, selecting from options provided.
5. Indicate if the service is court-ordered by selecting 'Yes' or 'No'. If 'Yes', ensure that a court order signed by a judge is attached to the form.
6. Answer whether the service is directed by the DFPS. If applicable, fill in the DFPS employee’s name and phone number and attach the directive or summary signed by the employee.
7. Fill out the Testing Requested section by indicating the type of testing required (psychological or neuropsychological). Remember to note the number of hours requested for testing.
8. In the Rationale supporting medical necessity for requested testing, indicate if the testing is for screening purposes and provide an explanation if applicable.
9. Summarize the previous history and testing results as needed. Document any relevant previous evaluations that may support the current request.
10. List the specific procedure codes being requested for the testing sessions.
11. Enter the dates for the testing period, specifying the start and end dates.
12. Complete the Provider Signature section by providing the printed name of the provider and their actual signature. Note that stamped signatures are not accepted.
13. Once all sections are filled out, review the entire form for accuracy and completeness. Save any changes, then download, print, or share the completed form as needed.

Complete your Psychological/Neuropsychological Testing Request Form online to ensure timely evaluation.