Get 3.704.1 Psychological/neuropsychological Evaluation Request Form

Completing the 3.704.1 Psychological/Neuropsychological Evaluation Request Form online is a straightforward process. This guide provides detailed instructions for each section of the form, ensuring that users can navigate it with ease and confidence.

Follow the steps to successfully complete the form online.

1. Click the ‘Get Form’ button to access the evaluation request form and open it in your preferred online document editor.
2. Enter the patient’s name and date of birth in the corresponding fields. Following that, provide the employee’s or subscriber’s name, their employer or insurance plan information, and the employee's social security number.
3. Indicate the patient’s relationship to the employee or subscriber. Next, fill in the name, degree, state license, and license number of the psychologist conducting the evaluation.
4. Choose whether the psychologist is part of a network or non-network by selecting the appropriate option. If the psychologist is independently licensed, indicate 'yes' or 'no'. Fill in the psychologist's address, telephone number, city, state, zip code, and Tax I.D. number.
5. In section C, specify who initiated the referral and provide details about their specialty if applicable. Describe the current symptoms and their duration, as well as the referral questions and reasons for requesting testing at this time.
6. Indicate if the patient has been evaluated by a psychiatrist, and if so, provide the date of the evaluation and current medications.
7. Input the current possible DSM-IV-TR diagnosis under evaluation. Complete the details for Axis I, Axis II, Axis III, Axis IV, and Axis V with the relevant information.
8. Summarize the patient’s history, including psychosocial and medical information, past treatment, and any previous psychological testing along with the dates and results.
9. Explain how the proposed testing will enhance treatment and impact future behavioral treatment. Specify whether the patient is currently in treatment, including the modality.
10. Discuss any psychological explanations for current behaviors or symptoms that may not be psychological in nature and detail these explanations.
11. List the planned tests and the estimated time required for each test. Indicate the proposed start date and ensure that you adhere to any relevant testing guidelines.
12. Finally, provide the psychologist's signature and date to complete the form.
13. Once all fields are filled, save your changes, and consider options to download, print, or share the form as needed.

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