A PSYCHOLOGICAL SERVICE PROVIDER IN WICHITA, KANSAS
Request for Psychological Evaluation
Client Name
Date of Birth
Does the client have a guardian?
Yes
No
Is the client currently in foster care?
Yes
No
Foster Care Information
Case Worker Name
Case Worker Phone
Case Worker Email
Contact Information
Parent or Guardian for minors
Full name
Full Address
Phone Number
Email
What is your main concern or purpose for requesting an evaluation?
Autism
ADHD
School Problems
Clarification of Diagnosis and Treatment recommendations
Other (please explain):
Is your provider Medicaid?
Yes
No
Please initial next to each statement to acknowledge them.
Failure to disclose primary insurance will result in a full cash charge. Do not report a secondary insurance without a primary insurance!
MKC Counseling, LLC accepts Blue Cross Blue Shield of Kansas, Aetna, all Medicaid plans, and Medicare. If your plan is not listed, you are responsible for calling the number on the back of your insurance card to see if we are a provider. If not, you may pay out of pocket for services.
You are responsible for calling your insurance plan using the number on the back of your card to check if pre-authorization is required for us to bill services through insurance. Not doing so may result in delayed scheduling.
Primary Insurance
Policyholder
Client
Parent
Insured Name
Insured DOB
Insured Address
Insured SSN
Insured Employer
Insurance Plan
Member ID
Copay
Deductible
Requires Pre-Authorization?
Add Secondary Insurance
Secondary Insurance
Insurance Plan
Member ID
Copay
Deductible
Requires Pre-Authorization?
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