If you are a professional wishing to make a referral for neuropsychological evaluation,
please print the following form and submit it by fax to (860) 449-0029.
Referral Form
If you are a patient and 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
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. Please note--an evaluation must be medically necessary to justify medical
insurance coverage. Evaluations for the purposes of accommodations on standardized
tests, evaluations for the FAA or other fitness-for-duty evaluations, court-ordered
evaluations, and certain other scenarios are not covered by insurance.

1. Ask if you have coverage for a neuropsychological interview (CPT 96116) and
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 (F09), 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

If you elect to pay for 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, prior to release of the written report.
Dr. Selden accepts cash, checks, and credit cards.

You can pay your bill by credit or debit card by clicking here:
Make a Payment
495 Gold Star Hwy, Suite 200         Groton, Connecticut 06340        (860) 449-0299