Behavioral Health Services
Psychological Testing Authorization Request
>> Incomplete forms may delay authorization <<
Please fax completed form to the Behavioral Health Access (BHA) fax number listed below. Providers may
request an urgent reauthorization by calling first, then faxing the form. Mailed forms are accepted as well.
BHA Fax: 206-901-6302 / Phone: 206-901-6300 or toll-free 1-888-287-2680
P.O. Box 34799, Seattle WA 98124-1799
Provider Name:
Consumer Name:
Agency:
Consumer Number:
Provider Signature:
Date of Birth:
Phone Number:
Authorization Number:
Today’s Date:
1. Reason for testing:
Who initiated the referral?
What are the referral questions?
2. Describe how the treatment plan will be affected by the results of testing:
3. What are the possible diagnoses under consideration?
4. History of patient (include any past psychological testing, dates and results):
5. Describe the results of treatment to date and the reason testing is indicated at this time:
CONFIDENTIAL
This information can be disclosed only with written consent of the person to whom it pertains or is
otherwise permitted by such regulations (Uniform Health Information Act Title 70.02)
Psychological Testing Authorization Request
Page 1 of 2
Revised 20120904
6. List tests being requested (do not use abbreviations):
Name of Test
To Measure or Answer What?
Number of testing hours being requested:
7. Comments:
Person Completing Form:
Name, Title (print)
CONFIDENTIAL
Signature
This information can be disclosed only with written consent of the person to whom it pertains or is
otherwise permitted by such regulations (Uniform Health Information Act Title 70.02)
Psychological Testing Authorization Request
Page 2 of 2
Revised 20120904