Alabama Medicaid Agency ABA Therapy Assessment Form (6/20/19) — Behavior Assessment and Treatment Request (CPT 97151) for Applied Behavioral Analysis for Autism Spectrum Disorder Instructions

Enter the recommended hours and setting for Caregiver/Parent Training sessions, indicating the number of units requested on the Prior Authorization.

Enter the CPT codes requested for Caregiver/Parent Training.

Enter the effective units requested to cover 6 months from the effective date for Caregiver/Parent Training.

Enter the effective date requested for Caregiver/Parent Training.

Provide the recommended hours and setting for direct patient support, indicating the number of sessions for patient/caregiver/parent training that reflect the units requested on the prior authorization.

Enter the CPT codes requested for direct patient support.

Provide the effective units requested to cover a period of 6 months from the effective date for direct patient support.

Enter the effective date requested for direct patient support.

Enter the baseline behaviors observed and the date for the fifth behavioral target.

Enter the specific behavior goal targeted for achievement within six months for the fifth behavioral target.

Enter the anticipated date for achieving the fifth behavioral target goal.

Enter the long-term goals associated with the fifth behavioral target.

Quantify the progress towards the fifth targeted behavior goals as a percentage.

Enter the baseline behaviors and date for the first behavioral target.

Enter the targeted behavior goal to be achieved within 6 months for the first behavioral target.

Enter the anticipated date for mastery of the first behavioral target.

Enter the long term goals for the first behavioral target.

Enter the percentage quantifying progress towards the targeted behavior goals for the first behavioral target.

Enter the baseline behaviors and the date for the fourth behavioral target.

Enter the targeted behavior goal to be achieved within 6 months for the fourth behavioral target.

Enter the target date by which the fourth behavioral goal is expected to be achieved.

Enter the long-term goals for the fourth behavioral target.

Enter the quantified progress in percentage toward the fourth targeted behavior goals for subsequent requests.

Enter any co-occurring behavioral health and medical diagnoses.

Provide information regarding current symptoms and relevant behavioral and medical history.

Briefly summarize your evaluation findings, including criteria of DSM-5, test scores, and observations in natural settings, and attach any other pertinent findings or information to support diagnoses.

Describe the coordination of the treatment plan with other providers, such as speech pathology, medical providers, school, outpatient psychologists, and teachers.

Outline the transition plan and the anticipated outcome of the treatment.

Provide details regarding the parent or caregiver training plan.

Enter the relationship of the parent or guardian to the recipient (patient).

Enter the email address of the parent or guardian.

Enter the street address of the parent or guardian.

Enter the city, state, and zip code of the parent or guardian.

Enter the full name of the patient.

Enter the patient's date of birth.

Enter the recipient's identification number.

Enter the patient's current diagnosis code(s).

Please provide details about any previous ABA treatment, including treatment dates, provider information, and results.

Enter the full name of the rendering provider.

Enter the National Provider Identifier (NPI) of the rendering provider.

Enter the full mailing address of the rendering provider.

Enter the tax identification number of the rendering provider.

Enter the primary phone number of the rendering provider.

Enter the email address of the rendering provider.

Enter the fax number of the rendering provider.

Enter the name of the contact person for the rendering provider.

Enter the job title of the contact person for the rendering provider.

Enter the phone number of the contact person for the rendering provider.

Check this box if the recipient has a current Individualized Education Program (IEP) or is currently receiving therapy through school-based services.

Check this box if the recipient does not have a current Individualized Education Program (IEP) and is not currently receiving therapy through school-based services.

Enter the patient's baseline behaviors and the date of assessment for the second behavioral target.

Enter the specific behavioral goal targeted to be achieved within six months for the second behavioral target.

Enter the target date by which the second behavioral goal is expected to be achieved.

Enter the long-term goals associated with the second behavioral target.

Enter the quantified progress toward the second behavioral target goal as a percentage.

Enter the baseline behaviors and date for the seventh behavioral target.

Enter the targeted behavior goal to be achieved within six months for the seventh behavioral target.

Enter the target date by which the seventh behavioral goal is expected to be achieved.

Enter the long-term goals for the seventh behavioral target.

Quantify the progress toward the seventh targeted behavior goals as a percentage.

Enter the baseline behaviors and the date for the sixth behavioral target.

Enter the targeted behavior goal to be achieved within 6 months for the sixth behavioral target.

Enter the target date by which the sixth behavioral goal is expected to be achieved.

Enter the long-term goals for the sixth behavioral target.

Enter the quantified progress toward the targeted behavior goals for the sixth behavioral target, as a percentage.

Enter the third baseline behaviors and the date they were observed.

Enter the third targeted behavior goal to be achieved within 6 months.

Enter the third target date by which the behavior goal is expected to be met.

Enter the third long-term goals related to the targeted behaviors.

Enter the percentage quantifying the third progress made toward the targeted behavior goals for subsequent requests.

Provide a detailed explanation of how ABA will be applied to the patient, including information on home and community-based 1-1 intervention and the number of hours per week for target goals.