The corresponding electronic version of the Extended Outpatient Psychotherapy/Counseling Request Form that is submitted through this website by choosing “Submit a Prior Authorization” will also be updated. An electronic version of the Psychological/Neuropsychological Testing Request Form will also be created and will be available on this website by choosing “Submit a Prior Authorization.”
Beginning January 1, 2010, all providers will be required to use the revised Extended Outpatient Psychotherapy/Counseling Request Form and the new Psychological/Neuropsychological Testing Request Form to request prior authorization for these services.
The changes to the Extended Outpatient Psychotherapy/Counseling Request Form are as follows:
· The form name has changed.
· The Current DSM IV Diagnosis field has been expanded to include Axis I through Axis V diagnoses.
· The following two new fields have been added to the form:
o Court ordered service?
o DFPS directed service?
If prior authorization is being requested in accordance with a court order or a Department of Family Protective Services (DFPS) directive, providers must submit the following additional information with the prior authorization request:
· If there is a court order, the court order signed by the judge must be submitted.
· If there is a DFPS directive, the DFPS directive or summary signed by the DFPS employee as well as the DFPS employee’s name and phone number must be submitted.
To view the paper forms click here:
Outpatient Psychotherapy/Counseling Request Form
Psychological/Neuropsychological Testing Request Form