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SUBMIT Utilization Management Department 125158 Research Blvd., Suite 400 Austin, Texas 78759 PHONE: 1,800. 716.5650 FAX 1.866.694.3649OUTPATIENT PSYCHOLOGICAL TESTING AUTHORIZATION REQUEST FORM Please
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How to fill out outpatient psychological testing authorization
How to fill out outpatient psychological testing authorization
01
Obtain the outpatient psychological testing authorization form from the relevant healthcare provider or facility.
02
Fill in your personal information such as your full name, date of birth, address, and contact details.
03
Provide information about your health insurance coverage, including the name of your insurance company and policy number.
04
Specify the reason for the outpatient psychological testing and the type of tests that need to be conducted.
05
You may need to provide additional information or documentation as requested by the healthcare provider, such as a referral from a physician or previous test results.
06
Review the completed form to ensure all information is accurate and complete.
07
Sign and date the form to indicate your consent for the outpatient psychological testing.
08
Submit the filled-out form to the healthcare provider or facility either in person, by mail, or through any online submission process they may have.
09
Keep a copy of the completed form for your records.
Who needs outpatient psychological testing authorization?
01
Any individual who requires outpatient psychological testing from a healthcare provider or facility needs outpatient psychological testing authorization. This may include individuals seeking diagnostic assessments, psychological evaluations, or other types of psychological testing. It is important to check with the specific healthcare provider or facility to confirm their requirements for obtaining authorization.
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