Get Psych Neuro Evaluation Request Form - Beacon Health Options

This guide provides a comprehensive overview of the Psych Neuro Evaluation Request Form for users seeking assistance in completing it online. Follow these detailed instructions to ensure an efficient and accurate submission.

Follow the steps to complete the Psych Neuro Evaluation Request Form seamlessly.

1. Press the ‘Get Form’ button to access the evaluation request form and open it in your preferred editor.
2. Begin with section A, entering the patient’s name, date of birth, the name of the employee or subscriber, their insurance plan, social security number, and the patient's relationship to the subscriber.
3. In section B, indicate whether the provider is a network or non-network psychologist and fill out their licensing information, including the degree and state license number.
4. Proceed to section C by identifying who initiated the referral, detailing current symptoms and their duration, stating the referral questions, and providing information on prior evaluations by a psychiatrist.
5. In section D, complete the current possible DSM-5 diagnosis, including behavioral and medical diagnoses, as well as any social elements affecting the diagnoses.
6. Utilize section E to summarize the patient’s psychosocial and medical history, mentioning any past treatment and psychological testing details, including dates and results.
7. In section F, describe how the proposed testing will enhance the treatment plan, including whether the patient is currently receiving treatment and specify the modality.
8. Fill out section G by noting any alternative explanations for current behaviors or symptoms and provide a brief explanation if necessary.
9. In section H, list the specific tests planned, estimated hours required, and the total time needed for administration, scoring, interpretation, and report writing.
10. Complete the proposed start date and provide the psychologist's signature along with the date to finalize the request.

Take the next step in managing care by completing the Psych Neuro Evaluation Request Form online.