Applied Behavior Analysis Clinical Service Request Form Instructions

Enter the date when the member began ABA services with the current provider or facility.

Specify the date when the member first received ABA services from any other provider. Fill only if the 'Has this member had ABA services with any other provider?' is 'Yes'.

Check this box if the member’s ABA services were provided at a focused intensity.

Enter the average number of hours per week that the member receives ABA services.

Check this box if the member’s ABA services have been continuous since the start.

Describe when and why the member had a break from ABA services. Fill only if the 'Continuous ABA services since start?' is 'No'.

Check this box if the member has not had ABA services with any other provider.

Check this box if the member has had ABA services with another provider.

Check this box if the member’s ABA services were provided at a comprehensive intensity.

Enter any additional procedure codes you are requesting along with the reason or clinical rationale for each code.

Enter the end time of the second additional therapeutic service session on Wednesday.

Enter the start time of the third additional therapeutic service session on Wednesday.

Enter the end time of the third additional therapeutic service session on Wednesday.

Enter the start time of the fourth additional therapeutic service session on Wednesday.

Check this box if the member is accessing physical therapy services in addition to ABA.

Check this box if the member is accessing occupational therapy services in addition to ABA.

Check this box if the member is accessing speech therapy services in addition to ABA.

Check this box if the member is not accessing any other therapeutic services besides ABA.

Enter the full mailing address of the administrative billing office responsible for processing claims and correspondence.

Enter the date on which the current assessment was completed and ensure it falls within the last 30 days.

Provide the full name of the professional who conducted the assessment.

Enter the license number or certification of the professional who conducted the assessment.

Check this box if the assessment was conducted with the patient only, without parents or caregivers present.

Check this box if the assessment was conducted with the patient’s parents or caregivers only, without the patient present.

Check this box if the assessment was conducted with both the patient and their parents or caregivers present.

Check this box if the member’s care is being coordinated with other medical or behavioral health providers.

Provide the names of the medical or behavioral health providers with whom you are coordinating care. Fill only if the 'Is there coordination of care with other medical or BH providers?' is 'Yes'.

Check this box if there is no coordination of care with other medical or behavioral health providers.

Enter the specific skill acquisition goals that are being carried over from the previous authorization period.

Enter the total number of skill acquisition goals carried over from the previous authorization period.

Check this box if you are the diagnostic practitioner certifying and recommending ABA services for the member.

Check this box if you are the ABA services supervisor, having confirmed with the diagnostician, and are certifying and recommending ABA services for the member.

Enter the official name of the clinic practice that will provide the ABA services.

Provide the clinic practice’s National Provider Identifier (NPI) number.

Enter the fax number where the clinic practice can receive documents.

Check this box if you are requesting a Focused level of service intensity for the ABA treatment.

Enter the total number of ABA service hours requested per week.

Enter the date on which the current ABA treatment request is to begin.

Check this box if you are requesting a Comprehensive level of service intensity for the ABA treatment.

Enter the patient’s primary ICD diagnosis code from the most recent diagnostic evaluation (must be no older than 36 months).

Enter the patient’s secondary ICD diagnosis code from the most recent diagnostic evaluation (if applicable).

Provide the date when the patient’s initial diagnostic evaluation was conducted.

Provide the date of the patient’s most recent diagnostic evaluation (must be within the last 36 months).

Enter the full name of the diagnostic practitioner who evaluated the patient.

Enter the National Provider Identifier (NPI) number of the diagnostic practitioner.

Check this box if the diagnostic practitioner, acting as the primary care provider, specializes in family practice.

Check this box if the diagnostic practitioner, acting as the primary care provider, specializes in internal medicine.

Check this box if the diagnostic practitioner, acting as the primary care provider, specializes in pediatrics.

Check this box if the diagnostic practitioner is a developmental behavioral pediatrician qualified as a specialized ASD-diagnosing provider.

Check this box if the diagnostic practitioner is a neurodevelopmental pediatrician qualified as a specialized ASD-diagnosing provider.

Check this box if the diagnostic practitioner is a child neurologist qualified as a specialized ASD-diagnosing provider.

Check this box if the diagnostic practitioner is an adult or child psychiatrist qualified as a specialized ASD-diagnosing provider.

Check this box if the diagnostic practitioner is a licensed clinical psychologist qualified as a specialized ASD-diagnosing provider.

Check this box if the diagnostic practitioner has another specialized ASD-diagnosing provider type; specify the type in the provided field.

Provide the name of the specialized ASD-diagnosing provider type not listed above. Fill only if the 'Other (specify)' is 'Yes'.

Provide the objective and measurable criteria that will define the patient’s discharge plan.

List any additional referrals or supports recommended at the time of discharge.

Check this box if the parent or caregiver agrees with the discharge plan.

Check this box if the parent or caregiver does not agree with the discharge plan.

Check this box if the patient has eating issues related to ASD.

Enter a description of any eating issues related to the patient’s ASD. Fill only if the 'Eating Issues Related to ASD' is 'Yes'.

Check this box if the patient does not have eating issues related to ASD.

Enter the name of the first assessment instrument that will be utilized for the member’s entire treatment episode.

Enter the date on which the current assessment was administered using this instrument.

Enter the score achieved on the current assessment using this instrument.

Enter the date on which the previous assessment was administered using this instrument.

Enter the score achieved on the previous assessment using this instrument.

Enter a brief description of the first maladaptive behavior exhibited by the patient.

Enter the number of times the first maladaptive behavior occurs per specified time unit (hour, session, day, or week).

Check this box when the frequency of the first maladaptive behavior is measured per hour.

Check this box when the frequency of the first maladaptive behavior is measured per session.

Check this box when the frequency of the first maladaptive behavior is measured per day.

Check this box when the frequency of the first maladaptive behavior is measured per week.

Enter the date when the parent/caregiver was first introduced to this training goal.

Enter the initial baseline percentage for this training goal.

Describe the measurable training goal that the parent/caregiver is expected to achieve.

Enter the current percentage progress or data for this training goal.

Enter the date by which the parent/caregiver is expected to master this training goal.

Enter a concise description of the member’s fourth maladaptive behavior.

Enter the number of times the fourth maladaptive behavior occurs within the specified time period.

Check this box if the frequency of the fourth maladaptive behavior is per hour.

Check this box if the frequency of the fourth maladaptive behavior is per session.

Check this box if the frequency of the fourth maladaptive behavior is per day.

Check this box if the frequency of the fourth maladaptive behavior is per week.

Enter the start time for the first ABA session on Friday.

Enter the end time for the first ABA session on Friday.

Enter the start time for the second ABA session on Friday.

Enter the end time for the second ABA session on Friday.

Enter the start time for the third ABA session on Friday.

Enter the end time for the third ABA session on Friday.

Enter the start time for the fourth ABA session on Friday.

Enter the end time for the fourth ABA session on Friday.

Check if the ABA sessions scheduled for Friday will take place at an office or clinic.

Provide details for any other location selected for ABA services on Friday.

Enter the lunch or break schedule for ABA services on Friday.

Check if the ABA sessions scheduled for Friday will take place in the community or at a daycare.

Check if the ABA sessions scheduled for Friday will take place at a location not listed and specify that location.

Check if the ABA sessions scheduled for Friday will take place at home.

Check if the ABA sessions scheduled for Friday will take place at school.

Enter the scheduled start time for the first school or therapy session on Friday.

Enter the scheduled end time for the first school or therapy session on Friday.

Enter the scheduled start time for the second school or therapy session on Friday.

Enter the scheduled end time for the second school or therapy session on Friday.

Enter the scheduled start time for the third school or therapy session on Friday.

Enter the scheduled end time for the third school or therapy session on Friday.

Enter the scheduled start time for the fourth school or therapy session on Friday.

Enter the scheduled end time for the fourth school or therapy session on Friday.

Check this box if the member has not received continuous ABA services since the start of treatment.

Provide the start time for the Tuesday session in the Other schedule.

Provide the end time for the Tuesday session in the Other schedule.

List the specific goals that were mastered during the previous authorization period.

Enter the total number of goals that were mastered during the previous authorization period.

Provide a description or list of the member’s skill acquisition goals that are currently on hold.

Enter the total number of the member’s skill acquisition goals that are currently on hold.

Check this box if the member currently has an IEP, ISP, 504 plan, or ARD in place.

Explain why the member does not have an IEP, ISP, 504, or ARD in place. Fill only if the 'Member has IEP, ISP, 504 or ARD in place?' is 'No'.

Check this box if the member does not currently have an IEP, ISP, 504 plan, or ARD in place.

Check this box if the patient is currently taking any medication.

Enter the name of the healthcare provider who prescribed the patient’s current medications. Fill only if the 'Is the patient taking medication?' is 'Yes'.

Enter the professional license or credential of the prescribing healthcare provider. Fill only if the 'Is the patient taking medication?' is 'Yes'.

Check this box if the patient is not taking any medication.

List all current medications and their dosages that the patient is taking. Fill only if the 'Is the patient taking medication?' is 'Yes'.

Enter the start time of the first ABA session scheduled on Monday.

Enter the end time of the first ABA session scheduled on Monday.

Enter the start time of the second ABA session scheduled on Monday.

Enter the end time of the second ABA session scheduled on Monday.

Enter the start time of the third ABA session scheduled on Monday.

Enter the end time of the third ABA session scheduled on Monday.

Enter the start time of the fourth ABA session scheduled on Monday.

Enter the end time of the fourth ABA session scheduled on Monday.

Check this box to indicate that ABA services on Monday are provided in an office or clinic setting.

Specify the location when 'Other' is selected in the location options. Fill only if the 'Monday Location Other' is 'Yes'.

Enter the lunch and break times for ABA services on Monday.

Check this box to indicate that ABA services on Monday are provided in a community or daycare setting.

Check this box if ABA services on Monday are provided at another location, and specify that location in the adjacent field.

Check this box to indicate that ABA services on Monday are provided at home.

Check this box to indicate that ABA services on Monday are provided at school.

Enter the start time of the first school or other therapy session scheduled on Monday.

Enter the end time of the first school or other therapy session scheduled on Monday.

Enter the start time of the second school or other therapy session scheduled on Monday.

Enter the end time of the second school or other therapy session scheduled on Monday.

Enter the start time of the third school or other therapy session scheduled on Monday.

Enter the end time of the third school or other therapy session scheduled on Monday.

Enter the start time of the fourth school or other therapy session scheduled on Monday.

Enter the end time of the fourth school or other therapy session scheduled on Monday.

List each new skill acquisition goal for the current authorization period.

Enter the total number of new skill acquisition goals for the current authorization period.

Enter a description of any additional member skill acquisition goals not covered by the listed categories.

Enter the total number of additional member skill acquisition goals described in the 'Other goals description' field.

Check this box if the member is accessing a public school program.

Specify the other school program the member is accessing. Fill only if the 'Member accessing other school program? Other' is 'Yes'.

Check this box if the member is accessing a private school program.

Check this box if the member is accessing a home school program.

Check this box if the member is accessing a school program not listed above and specify the program name.

Enter the number of hours per week the parent or caregiver is expected to participate in training sessions.

Enter the patient's full legal name.

Enter the patient's date of birth.

Enter the patient's full legal name.

Enter the patient's date of birth.

Enter the patient’s full legal name as it appears on their insurance policy.

Enter the patient’s date of birth in MM/DD/YYYY format.

Enter the date on which you are completing this form in MM/DD/YYYY format.

Enter the full name of the insurance subscriber under whom the patient is covered.

Enter the identification number assigned to the subscriber on the patient’s insurance card.

Enter the group number as shown on the patient’s insurance card.

Enter the U.S. state or territory in which the patient currently resides (e.g., IL for Illinois).

Enter the full legal name of the patient.

Enter the patient’s date of birth.

Enter the patient’s full legal name as it appears on their insurance or medical records.

Enter the patient’s date of birth.

Enter the full name of the primary contact person at the practice responsible for communications.

Enter the main telephone number for the practice contact, including area code.

Enter the telephone extension for the practice contact if applicable.

Enter the number of 15-minute service units requested for CPT code 97151 (assessment by a qualified healthcare professional).

Enter the number of 15-minute service units requested for CPT code 97152 (assessment by a technician).

Enter the number of 15-minute service units requested for CPT code 97153 (direct treatment by a technician or qualified healthcare professional).

Enter the number of 15-minute service units requested for CPT code 97155 (protocol modification and supervision of a technician by a qualified healthcare professional).

Enter the number of 15-minute service units requested for CPT code 97154 (group treatment by a technician or qualified healthcare professional).

Enter the number of 15-minute service units requested for CPT code 97158 (group protocol modification by a qualified healthcare professional).

Enter the number of 15-minute service units requested for CPT code 97156 (family treatment by a qualified healthcare professional).

Enter the number of 15-minute service units requested for CPT code 97157 (multi-family treatment by a qualified healthcare professional).

Enter the street address of the clinic practice where the rendering provider delivers services.

Enter the city in which the rendering provider’s clinic practice is located.

Enter the state abbreviation or full state name where the rendering provider’s clinic practice is located.

Enter the postal ZIP code for the rendering provider’s clinic practice address.

Check this box if you accept the number of units/days the clinical team determines is medically necessary and appropriate based on the clinical submission.

Check this box if you do not accept the number of units/days the clinical team determines is medically necessary and appropriate based on the clinical submission.

Enter the date the rendering provider signed and certified the qualifications.

Enter the full printed name of the rendering Qualified Healthcare Professional certifying this request.

Enter the name of the rendering provider's practice or organization.

Enter the master’s or PhD-level clinician’s state-recognized professional credential or certification (for example, BCBA or BCaBA).

Enter the two-letter abbreviation of the state that issued the above credential.

Enter the license or certification number associated with the credential provided above.

Enter the full name of the rendering qualified healthcare provider who is directly providing treatment.

Enter the National Provider Identifier (NPI) number for the rendering qualified healthcare provider.

Provide the email address of the rendering qualified healthcare provider.

Enter the telephone number, including a confidential voicemail line, for the rendering qualified healthcare provider.

Enter the telephone extension for the rendering qualified healthcare provider’s phone number.

Check this box if submitting an initial request for ABA services.

Check this box if submitting a concurrent request for ABA services.

Enter the start time of the first ABA session on Saturday.

Enter the end time of the first ABA session on Saturday.

Enter the start time of the second ABA session on Saturday.

Enter the end time of the second ABA session on Saturday.

Enter the start time of the third ABA session on Saturday.

Enter the end time of the third ABA session on Saturday.

Enter the start time of the fourth ABA session on Saturday.

Enter the end time of the fourth ABA session on Saturday.

Check if Saturday ABA services will be provided at the office or clinic.

Enter the name of the other location for Saturday ABA services if you selected Other.

Enter any scheduled lunch or break periods for Saturday ABA sessions.

Check if Saturday ABA services will be provided in the community or daycare.

Check if Saturday ABA services will be provided at another location and specify the location.

Check if Saturday ABA services will be provided at home.

Check if Saturday ABA services will be provided at school.

Enter the start time for the first Saturday school or therapy session.

Enter the end time for the first Saturday school or therapy session.

Enter the start time for the second Saturday school or therapy session.

Enter the end time for the second Saturday school or therapy session.

Enter the start time for the third Saturday school or therapy session.

Enter the end time for the third Saturday school or therapy session.

Enter the start time for the fourth Saturday school or therapy session.

Enter the end time for the fourth Saturday school or therapy session.

Provide the name of the second assessment instrument selected to measure the member’s treatment progress.

Enter the date when the current assessment was administered using the second instrument.

Enter the score obtained from the current administration of the second assessment instrument.

Enter the date of the previous administration of the second assessment instrument, if applicable.

Enter the score from the previous administration of the second assessment instrument, if applicable.

Provide a brief description of the second maladaptive behavior exhibited by the patient.

Enter the frequency count of how often the second maladaptive behavior occurs, relative to the selected time unit.

Check this box if the frequency of the second maladaptive behavior is measured per hour.

Check this box if the frequency of the second maladaptive behavior is measured per session.

Check this box if the frequency of the second maladaptive behavior is measured per day.

Check this box if the frequency of the second maladaptive behavior is measured per week.

Enter the date when the parent/caregiver was first introduced to the second training goal.

Enter the baseline percentage representing the parent/caregiver’s initial performance for the second training goal.

Provide a concise, measurable description of the second parent training goal to be achieved.

Enter the parent/caregiver’s current performance percentage or data tracking progress toward the second training goal.

Enter the date by which mastery of the second parent training goal is expected.

Check this box if the patient has sleep issues related to ASD.

Describe any sleep issues the patient experiences related to ASD. Fill only if the 'Sleep Issues Related to ASD' is 'Yes'.

Check this box if the patient does not have sleep issues related to ASD.

Enter the start time for the first ABA session on Sunday.

Enter the end time for the first ABA session on Sunday.

Enter the start time for the second ABA session on Sunday.

Enter the end time for the second ABA session on Sunday.

Enter the start time for the third ABA session on Sunday.

Enter the end time for the third ABA session on Sunday.

Enter the start time for the fourth ABA session on Sunday.

Enter the end time for the fourth ABA session on Sunday.

Check this box if the member will receive ABA services in an office or clinic on Sunday.

Specify any other location for ABA services on Sunday if none of the listed options apply.

Provide the lunch or break times planned for ABA services on Sunday.

Check this box if the member will receive ABA services in a community setting or daycare on Sunday.

Check this box if the member will receive ABA services at home on Sunday.

Check this box if the member will receive ABA services at school on Sunday.

Check this box if the member will receive ABA services at a location not listed on Sunday; specify the location.

Enter the start time for the first Sunday school or therapy session.

Enter the end time for the first Sunday school or therapy session.

Enter the start time for the second Sunday school or therapy session.

Enter the end time for the second Sunday school or therapy session.

Enter the start time for the third Sunday school or therapy session.

Enter the end time for the third Sunday school or therapy session.

Enter the start time for the fourth Sunday school or therapy session.

Enter the end time for the fourth Sunday school or therapy session.

Check this box to attest that as the ABA Supervisor you follow the outlined guidelines for supervision by the BACB and have an active license in the state where services are rendered. Fill only if the 'ABA Services Supervisor' is 'Yes'.

Check this box to indicate that as the ABA Supervisor you do not follow the outlined guidelines for supervision by the BACB and/or do not have an active license in the state where services are rendered. Fill only if the 'ABA Services Supervisor' is 'Yes'.

Enter the specific maladaptive behavior for the third entry.

Enter how often the third maladaptive behavior occurs, specifying the number and the time interval (e.g., per hour, session, day, or week).

Check this box if the frequency of the third maladaptive behavior is measured per hour.

Check this box if the frequency of the third maladaptive behavior is measured per session.

Check this box if the frequency of the third maladaptive behavior is measured per day.

Check this box if the frequency of the third maladaptive behavior is measured per week.

Enter the date on which the third parent training goal was introduced.

Enter the baseline percentage established for the third parent training goal.

Enter a detailed, measurable description of the third parent/caregiver training goal.

Enter the current progress as a percentage for the third parent training goal.

Enter the expected date by which mastery of the third parent training goal is anticipated.

Specify the start time of the first ABA session scheduled on Thursday.

Specify the end time of the first ABA session scheduled on Thursday.

Specify the start time of the second ABA session scheduled on Thursday.

Specify the end time of the second ABA session scheduled on Thursday.

Specify the start time of the third ABA session scheduled on Thursday.

Specify the end time of the third ABA session scheduled on Thursday.

Specify the start time of the fourth ABA session scheduled on Thursday.

Specify the end time of the fourth ABA session scheduled on Thursday.

Check this box if the ABA session on Thursday takes place at an office or clinic.

Specify the location details when 'Other' is checked for Thursday. Fill only if the 'Other' is 'Yes'.

Describe the lunch or break periods scheduled for Thursday.

Check this box if the ABA session on Thursday takes place at a location not listed above and specify that location.

Check this box if the ABA session on Thursday takes place in a community setting or daycare.

Check this box if the ABA session on Thursday takes place at the member’s home.

Check this box if the ABA session on Thursday takes place at a school.

Enter the start time for the fourth time span of Wednesday's School and Other Therapy Schedule.

Enter the end time for the fourth time span of Wednesday's School and Other Therapy Schedule.

Enter the start time for the first time span of Thursday's School and Other Therapy Schedule.

Enter the start time for the second time span of Thursday's School and Other Therapy Schedule.

Enter the end time for the second time span of Thursday's School and Other Therapy Schedule.

Enter the start time for the third time span of Thursday's School and Other Therapy Schedule.

Enter the end time for the third time span of Thursday's School and Other Therapy Schedule.

Enter the member’s current number of ABA service hours per week.

Enter the number of ABA service hours per week the member will step down to.

Provide the date on which the member’s ABA service hours reduction will take effect.

Enter the number of months within which the member’s ABA hours reduction will occur.

Describe the measurable criteria and objective targets that will guide the member’s ABA service fade plan.

Enter the start time of the first ABA session scheduled for Tuesday.

Enter the end time of the first ABA session scheduled for Tuesday.

Enter the start time of the second ABA session scheduled for Tuesday.

Enter the end time of the second ABA session scheduled for Tuesday.

Enter the start time of the third ABA session scheduled for Tuesday.

Enter the end time of the third ABA session scheduled for Tuesday.

Check this box if ABA therapy is scheduled at an office or clinic on Tuesday.

Provide details of the ABA session location for Tuesday when 'Other' is selected. Fill only if the 'Tuesday Location' is 'Other'.

Enter the scheduled lunch or break time for Tuesday's ABA sessions.

Check this box if ABA therapy is scheduled in a community or daycare setting on Tuesday.

Check this box if ABA therapy is scheduled at home on Tuesday.

Check this box if ABA therapy is scheduled at school on Tuesday.

Enter the start time of the first school or therapy session scheduled for Tuesday.

Enter the end time of the first school or therapy session scheduled for Tuesday.

Enter the start time of the second school or therapy session scheduled for Tuesday.

Enter the end time of the second school or therapy session scheduled for Tuesday.

Enter the start time of the third school or therapy session scheduled for Tuesday.

Enter the end time of the third school or therapy session scheduled for Tuesday.

Enter the start time of the fourth school or therapy session scheduled for Tuesday.

Enter the end time of the fourth school or therapy session scheduled for Tuesday.

Enter the start time of the first ABA session scheduled for Wednesday.

Enter the end time of the first ABA session scheduled for Wednesday.

Enter the end time of the fourth ABA session scheduled for Wednesday.

Check this box if ABA services on Wednesday will take place at an office or clinic.

Provide details of any other location used for ABA sessions on Wednesday. Fill only if the 'Other Location' is 'Yes'.

Enter any scheduled lunch or break times for ABA sessions on Wednesday.

Check this box if ABA services on Wednesday will take place in a community or daycare setting.

Check this box if ABA services on Wednesday will take place at another location and specify that location in the provided space.

Check this box if ABA services on Wednesday will take place in the patient’s home.

Check this box if ABA services on Wednesday will take place at school.

Enter the scheduled start time for the first school or therapy session on Wednesday.

Enter the scheduled end time for the first school or therapy session on Wednesday.

Enter the scheduled start time for the second school or therapy session on Wednesday.

Enter the scheduled end time for the second school or therapy session on Wednesday.

Enter the scheduled start time for the third school or therapy session on Wednesday.

Enter the scheduled end time for the third school or therapy session on Wednesday.