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Provider Request for Psychological/Neuropsychological Testing

Is the patient a minor? Required

In order to determine if testing is appropriate, insurance companies require information to justify medical necessity.

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Please complete the following: 

Is the patient aware that you are referring them for testing? Required
Has the patient been tested before? Required
Are any previous medical records available? Required
Upload File
PDF Please!
Has Imaging been ordered or completed? Required
Reason for Testing Required
Other psychological symptoms to be considered during testing:
Current Substance Use? Required
If Yes, what substances are used?
How long have these difficulties been going on? Required
Pre-surgical Evaluation ONLY:

Thank you for referring your patient to The Psychology Institute of Las Vegas. Our Assessment Team will review your request ASAP and reach out to your patient to schedule a consultation, and/or we will contact you for further information.

Thank you for referring your patient to The Psychology Institute of Las Vegas. Understand that when patients utilize their insurance coverage for psychological and neuropsychological testing services we are required to justify services based on “medical necessity”.  When completing this form:

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  1. Please indicate the need for testing services and include any clinical information to support your request, and

  2. Attach any medical records that support the patient’s current diagnosis and treatment history that is most related to the need for testing (i.e., most recent office visit notes indicating level of current impairment/concerns, radiology results, blood work, medication list, etc.)

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The PILV Assessment Team will review the referral information ASAP and determine if we can meet the needs of your request. 

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Thank you for allowing us to assist with your plan for patient care.

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Dr. Danielle Moreggi

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