NESCA Intake Form

PLEASE READ THESE INSURANCE FAQs CAREFULLY BEFORE COMPLETING THIS FORM

Does NESCA take insurance for neuropsychological evaluations?

For neuropsychological evaluations, Drs. Asher, Creedon, Currie, Gibbons, Hess, Kulis, Marchant, and Talamo are providers to Blue Cross Blue Shield.

NESCA does not bill any other insurance companies directly for evaluations. If you wish to seek partial reimbursement from your insurer, we will provide you with a detailed invoice (i.e. a superbill) at the conclusion of the evaluation.

Does insurance cover the full neuropsychological evaluation fee?

No. Health insurance companies provide coverage only for testing that meets their “medical necessity” criteria.

All evaluations at NESCA include testing that insurers consider “educational” and therefore do not fund. For this testing and subsequent feedback, you will be billed a separate fee for Educational Program Planning and Consultation Services.

If you have questions about your neuropsychological evaluation coverage, we encourage you to speak with your health insurance provider prior to completing this intake.

Does insurance cover transition services?

Transition consultation, planning, and assessment services are all considered “educational” services and are not covered by most insurance plans.

Child's Name *

Child's Date of Birth *

Current School

Current Grade:

Your Name: *

Your Telephone: *

Your Email Address: *

Alternate Phone:

Whose Phone (name):

Additional Parent/Guardian Name:

Email Address (Additional Parent/Guardian):

Address (line 1): *

Address (line 2):

City *

State *

ZIP *

Parent 1's Name

Parent 2's Name

Who has legal custody or guardianship? *

Parent 1

Parent 2

Both

Other: Other:

Health Insurance Provider * (NESCA does not accept Mass Health. For neuropsychological evaluation, NESCA is able to direct bill BCBS. We bill BCBS and All Ways for some occupational therapy and speech-language services. We bill Harvard Pilgrim for speech-language services only. We do not direct bill any other insurance companies or any other services.) *

Policy Number(s) for Child

Group Number

Policy Holder's Name:

Policy Holder's Date of Birth:

Referred by:

Referred to:

Which location would you prefer? *

Newton MA

Plainville MA (Foxboro area)

Londonderry NH (Neuropsychological & Psychological Evaluations Only)

Reason for Referral *

0/1024 characters

Diagnoses (if any):

Which services are you interested in? *Please note that NESCA only bills BCBS for neuropsychological services; We are able to bill BCBS, All Ways and Harvard Pilgrim for speech language services; We are no longer taking referrals for insurance-based occupational therapy services *