Applied Behavior Analysis (ABA) Initial Assessment Request Instructions
This form contains 69 fields organized into 19 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| ABA Assessment Code Units | ||
| 97151 QHP Units | Number |
Enter the total number of units requested for ABA assessment code 97151 performed by a Qualified Healthcare Provider (QHP).
|
| 97152 Technician Units | Number |
Enter the total number of units requested for ABA assessment code 97152 performed by a technician.
|
| Additional Code Request and Reason | ||
| Additional Code Request and Reason 1 | Text |
Provide details for the additional code request and the reason for it.
|
| Assessment Request End Date | ||
| Assessment Request End Date Month | Date |
Enter the month for the assessment request end date.
|
| Assessment Request End Date Day | Date |
Enter the day for the assessment request end date.
|
| Assessment Request End Date Year | Date |
Enter the year for the assessment request end date.
|
| Assessment Request Start Date | ||
| Assessment Request Start Date Month | Date |
Provide the month for the assessment request start date.
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| Assessment Request Start Date Day | Date |
Provide the day for the assessment request start date.
|
| Assessment Request Start Date Year | Date |
Provide the year for the assessment request start date.
|
| Billing Contact Information | ||
| Billing Contact Name | Text |
Enter the full name of the billing contact.
|
| Billing Contact Telephone | Text |
Enter the telephone number for the billing contact.
|
| Billing Contact Telephone Extension | Text |
Enter the telephone extension for the billing contact.
|
| Diagnosis Codes | ||
| Primary Diagnosis Code | Text |
Enter the primary diagnosis code for the patient.
|
| Secondary Diagnosis Code | Text |
Enter any secondary diagnosis code for the patient.
|
| Diagnostic Practitioner Information | ||
| Diagnostic Practitioner Name | Text |
Provide the full name of the diagnostic practitioner.
|
| NPI | Text |
Enter the National Provider Identifier (NPI) of the diagnostic practitioner.
|
| Telephone | Text |
Provide the telephone number of the diagnostic practitioner.
|
| Fax Number | Text |
Provide the fax number of the diagnostic practitioner.
|
| Contact Name | Text |
Provide the name of the contact person for the diagnostic practitioner.
|
| General | ||
| Rendering QHP Signature | Signature | |
| Initial Evaluation Date | ||
| Initial Evaluation Month | Text |
Enter the month component of the initial evaluation date.
|
| Initial Evaluation Day | Text |
Enter the day component of the initial evaluation date.
|
| Initial Evaluation Year | Text |
Enter the year component of the initial evaluation date.
|
| Most Recent Evaluation Date | ||
| Most Recent Evaluation Date Month | Date |
Enter the month of the most recent evaluation.
|
| Most Recent Evaluation Date Day | Date |
Enter the day of the most recent evaluation.
|
| Most Recent Evaluation Date Year | Date |
Enter the year of the most recent evaluation.
|
| Patient Information | ||
| Patient Name | Text |
Enter the full name of the patient.
|
| Patient Date of Birth | Date |
Enter the patient's date of birth.
|
| Request Submission Date | Date |
Enter the date this request is being submitted.
|
| Subscriber Name | Text |
Enter the full name of the subscriber.
|
| Subscriber ID | Text |
Enter the subscriber's identification number.
|
| Group Number | Text |
Enter the group number associated with the insurance policy.
|
| Patient Residence State | Text |
Enter the state where the patient resides.
|
| Services in Same State Yes | Radiobutton |
Check this box if the services for the patient are conducted in the same state where the patient resides.
|
| Services State (if different) | Text |
If services are not conducted in the same state as the patient's residence, enter the state where services are conducted.
|
| PCP Type Family Practice | Checkbox |
Check this box if the Diagnostic Practitioner Type (PCP) is Family Practice.
|
| PCP Diagnostic Practitioner Type | ||
| Internal Medicine | Checkbox |
Check this box if the PCP diagnostic practitioner's type is Internal Medicine.
|
| Pediatrics | Checkbox |
Check this box if the PCP diagnostic practitioner's type is Pediatrics.
|
| Check Box5 | CheckBox | |
| Practice Address | ||
| Practice Address | Text |
Enter the street address for the practice.
|
| Practice City | Text |
Enter the city where the practice is located.
|
| Practice State | Text |
Enter the state where the practice is located.
|
| Practice Zip Code | Text |
Enter the zip code for the practice address.
|
| Practice Contact Information | ||
| Practice Contact Name | Text |
Please provide the full name of the practice contact.
|
| Practice Contact Telephone Number | Text |
Please provide the telephone number for the practice contact.
|
| Practice Contact Telephone Extension | Text |
Please provide the telephone extension for the practice contact.
|
| Practice Information | ||
| Practice Name | Text |
Provide the full legal name of the practice.
|
| Practice NPI | Text |
Provide the National Provider Identifier (NPI) for the practice.
|
| Practice Fax Number | Text |
Provide the fax number for the practice.
|
| Provider Certification | ||
| Certification Date Month | Date |
Enter the month of the certification date.
|
| Certification Date Day | Date |
Enter the day of the certification date.
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| Certification Date Year | Date |
Enter the year of the certification date.
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| Rendering QHP Printed Name | Text |
Enter the printed name of the Rendering Qualified Healthcare Provider (QHP).
|
| Certification Practice Name | Text |
Enter the name of the practice for this certification.
|
| Provider Credentials | ||
| Master's/PhD Credential or Certification | Text |
Please enter the Master's/PhD level clinician's state-recognized professional credential or certification.
|
| Credential State | Text |
Please enter the state where the professional credential or certification was obtained.
|
| License/Certification Number | Text |
Please enter the license or certification number for the clinician.
|
| Rendering QHP Information | ||
| Rendering QHP Name | Text |
Enter the full name of the Rendering Qualified Healthcare Provider (QHP) who is directly providing treatment.
|
| Rendering QHP NPI | Text |
Enter the National Provider Identifier (NPI) for the Rendering Qualified Healthcare Provider (QHP).
|
| Rendering QHP Email | Text |
Enter the email address for the Rendering Qualified Healthcare Provider (QHP).
|
| Rendering QHP Telephone | Text |
Enter the telephone number for the Rendering Qualified Healthcare Provider (QHP).
|
| Rendering QHP Telephone Extension | Text |
Enter the telephone extension for the Rendering Qualified Healthcare Provider (QHP), if applicable.
|
| Specialized ASD-Diagnosing Provider Type | ||
| Neurodevelopmental Pediatrics | Checkbox |
Check this box if the specialized ASD-diagnosing provider type is Neurodevelopmental Pediatrics.
|
| Child Neurology | Checkbox |
Check this box if the specialized ASD-diagnosing provider type is Child Neurology.
|
| Adult or Child Psychiatry | Checkbox |
Check this box if the specialized ASD-diagnosing provider type is Adult or Child Psychiatry.
|
| Licensed Clinical Psychology | Checkbox |
Check this box if the specialized ASD-diagnosing provider type is Licensed Clinical Psychology.
|
| Other (specify) | Checkbox |
Check this box if the specialized ASD-diagnosing provider type is not listed and specify it in the provided space.
|
| Specialized ASD-Diagnosing Provider Type - Other | Text |
Please specify the specialized ASD-diagnosing provider type if it is not among the listed options.
|
| Group1_No | RadioButton | |