• REFERRAL FOR SERVICES

    REFERRAL FOR SERVICES

  • Individual Demographics

    The below questions pertain to the individual to be seen.
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  • Psychiatric ICD-10 Diagnosis Codes:

  • Medical ICD-10 Diagnosis Codes:

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  • (Note: If start date is prior to the request received date, it must be requested as a retrospective review and may be denied for non-compliance

  • Contact information

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  • Please answer all that apply

    Leave blank if not applicable
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  • Evaluation Services (Note: One unit equals one hour

    Integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning, report writing and feedback to patient/family member:

  • Test Administration and Scoring (Note: One unit equals 30 minutes

    Specific psychological tests being requested (full name of test written out) with specified time for each one:

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  • Should be Empty: