Psychological Testing Authorization Request Form

This document serves as a Psychological/Neuropsychological Testing Authorization Request Form required for providers submitting requests for psychological testing services. It details necessary patient information, including medication history and required documentation such as psychiatric evaluations. The form includes sections for specifying the tests to be used and for describing the patient’s symptoms and prior assessments. It outlines regulations regarding covered diagnoses for Medicaid members in Colorado. Providers must submit the completed form along with supporting documentation to ensure timely processing of the request.