Behavioral health services telephone: 1-800-454-3730 fax: 1-800-505-1193-2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in the general information section. Enter the member's name, date of birth (DOB), age, and address. Ensure that you also include the psychologist's name, provider number, phone number, email, and NPI.
3. In the clinical assessment section, check all relevant assessments completed prior to this request. This may include psychiatric evaluations or consultations.
4. Detail the clinical information by indicating presenting problems and symptoms. Check all applicable boxes to accurately reflect the member's condition.
5. Provide treatment history by specifying how often services are received and whether the member is still in treatment. Include any pertinent information that supports your request.
6. Complete the rationale for testing section by describing why testing is necessary and how it will impact treatment decisions.
7. Finally, ensure all fields are filled out clearly before submitting your request for psychological testing authorization.

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