The testing provider must complete Section XI, Requested Testing and, if applicable, Section XIII, 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 healthcare 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. Out-of-network provider: Send this completed form to Magellan Healthcare 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 card.
Please print clearly - Complete all items - Incomplete forms cannot be processed.
Medical/Psychological Evaluation and Treatment