Mainehealth Accountable Care Organization

MaineHealth Accountable Care Organization

Behavioral HealthCare Program

110 Free Street, Portland, ME 04101 – 800-538-9698 – (Fax) (207) 761-3079

PSYCHOLOGICAL AND NEUROPSYCHOLOGICAL TESTING REQUEST FORM

This form is applicable only for requests related to the treatment of a mental health disorder, any medical related requests should be directed to the medical plan of the member’s insurance plan. This form is not applicable for any Neuropsychological testing requests for Martin’s Point USFHP and Generations Advantage members.

Member Name: Member’s DOB:______

Member ID#:______Testing dates requested: Start:______End:______

Referring Provider:______Phone:______

Brief Case Information/Purpose of the Requested Testing: (What questions do you want answered with these tests?)

Testing Court Ordered?: Yes_____No_____

ICD Diagnostic Code Number and DSM 5 Diagnosis (If none currently, enter none”):______

Psychologist Name:______Address:______

______Phone:______Fax:______

Degree:______License #:______Tax ID#______NPI#______

List All Tests Required:______

______

Total Hours of Authorization Requested for:

Psychological Testing (CPT 96101):______Neuropsychological Testing (CPT 96118):______

Initial Evaluation/Feedback Session Requested: CPT Code: 90791_____ CPT Code: 90837_____

CPT Code: 90846_____

Provider Signature:______Date:______

BHCP Only:

BHCP Approval:______Date:______