Follow the steps to successfully complete the request form online.

1. Click the ‘Get Form’ button to access the Psychological/Neuropsychological Testing Request form and open it in your preferred software or document editor.
2. Begin by entering the date of the request at the top of the form. Ensure this is accurate as it signifies when the request is made.
3. Fill in the member's name, member ID number, and date of birth comprehensively to ensure easy identification.
4. Provide your name and discipline as the testing provider, including your provider ID, phone number, and extension, where applicable.
5. Indicate the mailing address for the testing provider. Be precise to prevent any communication delays.
6. Select whether you are an in-plan or out-of-plan provider, based on the member’s policy.
7. Identify the individual to be notified of the decision regarding the testing request by providing their name and phone number.
8. Specify the type of testing requested by marking appropriate boxes for neuropsychological or psychological testing and by detailing any specific tests required.
9. Document the primary diagnosis for which testing is being requested, and provide a list of any other diagnoses if applicable.
10. Clearly outline the patient's current symptoms to provide context for the testing request.
11. Define the diagnostic and treatment questions that you believe the testing will address.
12. Confirm whether a comprehensive clinical evaluation has been completed within the last 12 months. If yes, include details of who conducted it and when.
13. If a comprehensive evaluation has not been completed, explain clearly why it is not possible and how that impacts the request.
14. Describe how the results of the testing will influence treatment decisions.
15. Note any prior psychological testing that has been performed, including dates and the reviewing clinician.
16. List all current treatment providers with relevant details about their roles and dates of treatment.
17. Address the pharmacological consultation status. Provide medication information if applicable.
18. For patients under 18, confirm school communication and eligibility evaluations, detailing any relevant reports and special services.
19. Complete the name, discipline, provider ID, phone number, extension, and mailing address for the requesting clinician.
20. Finally, indicate your relationship to the patient, who referred them, the count of meetings, and the last contact date. Make sure to sign and date the form, as unsigned forms will be returned for completion.
21. After filling out all sections accurately, save any changes made to the document. You may opt to download, print, or share the completed form as needed.

Begin the process of completing the Psychological/Neuropsychological Testing Request form online today for efficient and accurate submission.