Transcription of Request For Psychological Testing Preauthorization
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Request For Psychological Testing Preauthorization
Request For Psychological Testing Preauthorization Revised 06/16/2015 Page 1 of 2 Version This document is confidential and the proprietary information of Magellan. The Testing provider must complete Section XI, Requested Testing and, if applicable, Section XII, Technician Attestation. Either the referring provider or the Testing provider may complete other sections of the form. Please provide all requested information, subject to applicable law. In most cases, an initial assessment by a behavioral health care provider must be administered before Psychological Testing will be authorized. Authorization for Psychological Testing will not be considered until all sections of this form are completed. To avoid potential issues with reimbursement, Psychological Testing should not be initiated until an authorization has been received. Please send the completed form to: Magellan Health Services at the address or fax number located on authorization correspondence received for this member, or obtain the proper address/fax number by calling the phone number on the member s benefit Please Print Clearly I.
Request For Psychological Testing Preauthorization Revised 06/16/2015 Page 2 of 2 Version 10.7 This document is confidential and the proprietary information of Magellan.
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