Get the free 3.704.1 Psychological/Neuropsychological Evaluation Request Form

This document is a request form for psychological and neuropsychological evaluations, gathering patient details, referral information, current symptoms, diagnosis, history, and testing plans.

How to fill out 37041 psychologicalneuropsychological evaluation request

How to fill out 3.704.1 Psychological/Neuropsychological Evaluation Request Form

1. Obtain the 3.704.1 Psychological/Neuropsychological Evaluation Request Form from the appropriate source.
2. Fill out the patient's personal information at the top of the form, including name, date of birth, and identification number.
3. Provide the referral information, including the name of the referring professional and their contact information.
4. Specify the reason for the evaluation in the designated section, detailing any concerns or symptoms.
5. Indicate any relevant medical history, including previous diagnoses or treatments related to psychological or neuropsychological issues.
6. Include information about any medications the patient is currently taking.
7. Complete any additional sections related to consent and confidentiality as required.
8. Review the form for accuracy and completeness before submission.
9. Submit the form to the appropriate evaluation center or professional.

Who needs 3.704.1 Psychological/Neuropsychological Evaluation Request Form?

1. Healthcare providers who require a psychological or neuropsychological evaluation for their patients.
2. Referral sources such as psychologists, psychiatrists, or neurologists.
3. Parents or guardians seeking evaluation for their children.
4. Individuals applying for disability benefits who need a psychological evaluation.

People Also Ask about

How to get a neuropsychological evaluation?

The best place to start if you have concerns about your memory or cognition is with your doctor. A referral directly from your medical provider can help facilitate the scheduling process, including authorization for health care insurance coverage.

How do I get a full neuropsych eval?

The best place to start if you have concerns about your memory or cognition is with your doctor. A referral directly from your medical provider can help facilitate the scheduling process, including authorization for health care insurance coverage.

Who should get a neuropsychological evaluation?

We provide neuropsychology assessments for individuals with: Acquired brain injury (concussion and traumatic brain injury) Cerebrovascular disease and stroke. Epilepsy and seizure disorder. Dementia and mild cognitive impairment. Movement disorders (e.g., Parkinson's disease, Huntington's disease)

Who completes a neuropsychological evaluation?

A neuropsychologist completes a neuropsychological evaluation. A neuropsychologist is a licensed clinical or school psychologist (with a Psy. D. or Ph.

What is an example of a neuropsychological evaluation?

Examples of tests you may encounter during a neuropsychological evaluation include: Wechsler Adult Intelligence Scale: An IQ test. Assesses intelligence, cognitive ability, memory, and processing speed through visual puzzles, block design, matrices, and other methods. Weschler Memory Scale: Tests memory.

What is the average cost of a neuropsychological evaluation?

Another thing to know about your own situation is the deductible and co-pay. For cases under the Medical Benefit, the co-pay may be something like 20 percent. Since a Neuropsychological Evaluation usually costs between $2500-$3500, then the co-pay would be $500 or more. This $500 will be applied towards your co-pay.

What is the CPT code for neuropsychological testing?

- The first hour of neuropsychological evaluation is billed using 96132 and each additional hour needed to complete the service is billed with code 96133. - CPT Time Rules allow an additional unit of a time-based code to be reported as long as the mid-point of the stated amount of time is passed.

How to read neuropsychological evaluation results?

Standard scores, which are commonly reported among neuropsychological tests, have an average of 100. The further away a person's score is from 100, the greater the difference was between their performance on the test compared to most individuals their age.

For pdfFiller’s FAQs

What is 3.704.1 Psychological/Neuropsychological Evaluation Request Form?

The 3.704.1 Psychological/Neuropsychological Evaluation Request Form is a standardized document used to request a psychological or neuropsychological evaluation for an individual. It serves to collect necessary information for the assessment process.

Who is required to file 3.704.1 Psychological/Neuropsychological Evaluation Request Form?

Typically, the form must be filed by healthcare providers, such as physicians or psychologists, who identify the need for a psychological or neuropsychological evaluation for their patient.

How to fill out 3.704.1 Psychological/Neuropsychological Evaluation Request Form?

To fill out the form, the requester should provide detailed patient information, including demographics, medical history, the reason for the evaluation, and any specific concerns or symptoms that need to be assessed.

What is the purpose of 3.704.1 Psychological/Neuropsychological Evaluation Request Form?

The purpose of the form is to formally document the request for evaluation, ensuring that all relevant information is communicated to the evaluating professional to facilitate an accurate assessment.

What information must be reported on 3.704.1 Psychological/Neuropsychological Evaluation Request Form?

The form must report essential information such as the patient's identification details, the referring provider's information, clinical history, specific concerns or symptoms, and any relevant test results or previous evaluations.