MKC - Services | Psych Evaluation Form

Please read and acknowledge the following

We accept the following insurance plans: Aetna, Blue Cross Blue Shield, all Kansas Medicaids (United Health, Sunflower, Healthy Blue), Medicare on a case-by-case basis, Humana, Cigna, Meritain, Luminare, and all plans administered by ProviDrs Care.

We do not accept Tricare, Ambetter, United Healthcare, and some Medicare plans. If you have Medicaid as a secondary insurance but we do not accept your primary insurance, Medicaid will not cover any part of your bill. If you do not have insurance or have a primary insurance we do not accept, our cash rate is $1,440 and is due upon completion of your evaluation.

I have read and understand the insurance information above.

Primary Insurance Plan

Policyholder Relationship to Client

Policyholder's Name

Policyholder's DOB

Policyholder's Address

Policyholder's Phone Number

Policyholder's SSN

Policyholder's Employer

Insurance Plan Name

Member Id

Copay

Deductible

Requires Pre Authorization? Yes No

Do you have secondary insurance? Yes No

Request for Psychological Evaluation

Client Information

Contact Information for Case Worker

Contact Information for Parent, Guardian, or Placement Home

Please read and acknowledge the following

Medicaid Insurance Information

Primary Insurance Plan

Secondary Insurance Plan