ABA Authorization Request (Medi-Cal) – Initial and Concurrent Requests Instructions
This form contains 37 fields organized into 11 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Adaptive Behavior Treatment (H2019) | ||
| H2019 Hours Per Week | Number |
Enter the number of hours per week for the H2019 Adaptive Behavior Treatment.
|
| H2019 Units Requested | Number |
Enter the total number of units requested for the H2019 Adaptive Behavior Treatment.
|
| Adaptive Behavior Treatment with Protocol Modification (H2012) | ||
| H2012 Hours Per Week | Number |
Enter the number of hours per week for Adaptive Behavior Treatment with Protocol Modification (H2012).
|
| H2012 Units Requested | Number |
Enter the number of units requested for Adaptive Behavior Treatment with Protocol Modification (H2012).
|
| Behavior Identification Assessment (H0031) | ||
| H0031 Units Requested | Text |
Enter the number of units requested for the H0031 behavior identification assessment.
|
| Family Adaptive Behavior Treatment Guidance (S5111) | ||
| S5111 Hours per Month | Number |
Enter the number of hours per month for S5111 Family Adaptive Behavior Treatment Guidance.
|
| S5111 Units Requested | Number |
Enter the number of units requested for S5111 Family Adaptive Behavior Treatment Guidance.
|
| Group Adaptive Behavior Treatment (H0014) | ||
| H0014 Hours per Week | Number |
Provide the number of hours per week for Group Adaptive Behavior Treatment (H0014).
|
| H0014 Units Requested | Number |
Provide the number of units requested for Group Adaptive Behavior Treatment (H0014).
|
| Patient Information | ||
| Patient's Name | Text |
Please provide the full name of the patient.
|
| Patient's Date of Birth | Date |
Please enter the patient's date of birth.
|
| Patient's Age | Text |
Please provide the patient's current age.
|
| Patient's Other Gender | Text |
If the patient's gender is not Male or Female, please specify it here.
|
| Patient's Phone Number | Text |
Please enter the patient's primary phone number.
|
| Patient's Insurance ID | Text |
Please provide the patient's insurance identification number.
|
| Patient's Employer/Benefit Plan | Text |
Please enter the patient's employer or benefit plan name.
|
| Patient Name | Text |
Please enter the full name of the patient.
|
| Patient ID Number | Text |
Please enter the patient's identification number.
|
| Program Setting and Hours per Week | ||
| Home Hours per Week | Number |
Enter the number of hours per week for services provided in a home setting.
|
| Facility/Clinic Hours per Week | Number |
Enter the number of hours per week for services provided in a facility or clinic setting.
|
| School Hours per Week | Number |
Enter the number of hours per week for services provided in a school setting.
|
| Other Setting Hours per Week | Number |
Enter the number of hours per week for services provided in an unspecified setting.
|
| Provider Group/Agency Information | ||
| Provider Group/Agency Name | Text |
Enter the name of the provider group or agency.
|
| TIN Number | Text |
Enter the Taxpayer Identification Number (TIN) of the provider group or agency.
|
| Provider Group ID (if known) | Text |
Enter the Provider Group ID if it is known.
|
| Service Address | Text |
Enter the street address for the service location of the provider group or agency.
|
| City/State/Zip Code | Text |
Enter the city, state, and zip code for the service location of the provider group or agency.
|
| Phone Number | Text |
Enter the contact phone number for the provider group or agency.
|
| Email Address | Text |
Enter the contact email address for the provider group or agency.
|
| Provider/Supervisor Information | ||
| Provider/Supervisor Name | Text |
Enter the full name of the provider or supervisor.
|
| Certification/License Number | Text |
Enter the certification or license number for the provider or supervisor.
|
| Certification/License State | Text |
Enter the state where the provider or supervisor's certification or license was issued.
|
| NPI Number | Number |
Enter the National Provider Identifier (NPI) for the provider or supervisor.
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| Provider/Supervisor Phone Number | Text |
Enter the phone number of the provider or supervisor.
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| Provider/Supervisor Email Address | Text |
Enter the email address of the provider or supervisor.
|
| Requested Start Date for this Authorization | ||
| Requested Start Date | Date |
Enter the requested start date for this authorization.
|
| Treatment Planning/Re-assessment (H0032) | ||
| H0032 Units Requested for Authorization Period | Text |
Provide the number of units requested for the authorization period for Treatment Planning/Re-assessment (H0032).
|