Get Neuropsychological Testing Request Form - Providers Amerigroup

This guide provides a step-by-step approach for completing the Neuropsychological Testing Request Form - Providers Amerigroup online. The instructions aim to simplify the process and ensure that all necessary information is accurately captured.

Follow the steps to effectively complete the form.

1. Press the ‘Get Form’ button to access the Neuropsychological Testing Request Form and open it in your preferred online platform.
2. Begin by filling out the general information section. Enter the member's name, date of birth, psychologist's name, Amerigroup provider number, contact phone number, address, provider NPI number, provider email, referral source, specialty, age, Amerigroup member ID, and their address again, along with fax number.
3. In the clinical information section, review previous medical records for relevant details that support the request for testing. Mark the applicable conditions such as traumatic brain injury, cognitive impairment, or major affective disorders, and include the specific dates.
4. Proceed to the clinical assessment. Document any clinical interview dates, evaluations, neuroimaging, and related assessments performed on the member to provide a comprehensive view of the patient's health status.
5. Indicate if the patient has had previous psychological or neuropsychological testing, specifying the date and results if applicable. Also, list any medications the patient is currently taking or mark 'None' if applicable.
6. Answer additional questions regarding substance abuse history and how the proposed neuropsychological testing will affect treatment planning.
7. List the specific neuropsychological tests that are requested, mentioning the expected administration time for each test. If necessary, attach additional sheets to specify more tests.
8. Finalize the form by signing it and entering the date it was completed. Ensure all information is legible and correct before submission. Users can save changes, download, print, or share the completed form.

Complete your Neuropsychological Testing Request Form online to ensure a smooth submission process.