To make a referral for neuropsychological evaluation, please print the following form and
submit it by fax to (860) 449-0029.
Referral Form
submit it by fax to (860) 449-0029.
Referral Form
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If you already have an appointment scheduled, please print the following forms, complete
them, and bring them to your appointment. If your child is scheduled for an appointment,
please complete the forms from your child's perspective:
Evaluation Consent Form
Contact Information Form
them, and bring them to your appointment. If your child is scheduled for an appointment,
please complete the forms from your child's perspective:
Evaluation Consent Form
Contact Information Form
I encourage you to check with your insurance provider to ensure that neuropsychological
evaluation is a covered procedure. If it is not covered, you ultimately are responsible for
your bill.
1. Ask if you have coverage for neuropsychological testing (CPT 96118)?
2. If so, is pre-authorization needed?
3. If Dr. Selden does not accept your insurance, ask your insurance company what your
out-of-network benefits are for neuropsychological testing. You will be responsible for
payment to Dr. Selden directly, and she will assist you in receiving reimbursement (if
available) for the evaluation.
4. Is there a maximum number of units of 96118?
5. If asked, say that the diagnosis is Cognitive Disorder Not Otherwise Specified (294.9),
a purposefully vague diagnosis because we are trying to determine what, if anything, is
going on.
evaluation is a covered procedure. If it is not covered, you ultimately are responsible for
your bill.
1. Ask if you have coverage for neuropsychological testing (CPT 96118)?
2. If so, is pre-authorization needed?
3. If Dr. Selden does not accept your insurance, ask your insurance company what your
out-of-network benefits are for neuropsychological testing. You will be responsible for
payment to Dr. Selden directly, and she will assist you in receiving reimbursement (if
available) for the evaluation.
4. Is there a maximum number of units of 96118?
5. If asked, say that the diagnosis is Cognitive Disorder Not Otherwise Specified (294.9),
a purposefully vague diagnosis because we are trying to determine what, if anything, is
going on.
Jennifer Selden, Ph.D.
psychological and neuropsychological evaluations across the lifespan
psychological and neuropsychological evaluations across the lifespan
If you elect to pay for the evaluation, which ranges from $1200-$2500 depending on the
nature of the evaluation, out of pocket, this typically is paid in two installments: 1/2 of the
estimated total due at the time of the initial interview and the remainder at the time of the
feedback appointment. Dr. Selden accepts credit cards, along with cash and checks, to
assist families in paying for the evaluation.
nature of the evaluation, out of pocket, this typically is paid in two installments: 1/2 of the
estimated total due at the time of the initial interview and the remainder at the time of the
feedback appointment. Dr. Selden accepts credit cards, along with cash and checks, to
assist families in paying for the evaluation.
| 495 Gold Star Hwy, Suite 200 Groton, Connecticut 06340 (860) 449-0299 |