Applied Behavior Analysis for Autism Initial Assessment and Goals and Six Month Reassessment of Goals and Treatment Plan (MMFRM-18) Instructions

Enter the name of the person at the provider's office to notify with the authorization decision, including their phone number if it is different than the one previously provided.

Provide the number of hours per day requested for authorization.

Provide the number of days per week requested for authorization.

Provide the total duration of the authorization in months.

Enter the full name of the BCBA professional who will perform or supervise the service.

Provide a list of clinical evaluation measurement tools used in evaluation, development of treatment plan, and goals.

Enter the name of the person or entity who completed the comprehensive diagnostic evaluation.

Enter the date when the comprehensive diagnostic evaluation was completed.

Enter the code for the eighth service.

Enter a description of the eighth service.

Enter the frequency for the eighth service.

Enter the units for the eighth service.

Enter the date of the initial evaluation.

Enter the date of the six-month re-evaluation and update.

Check this box if the patient has had a medication consultation.

Check this box if the patient has not had a medication consultation.

Enter the date when this fifth target behavior was identified.

Describe the fifth target behavior identified for increase.

Describe the specific goal for the fifth target behavior.

Provide the current level of functioning related to the fifth target behavior.

Enter the target date by which the fifth behavior goal is expected to be completed.

Provide the status of the fifth behavior goal at the time of the 6-month re-evaluation, including any relevant details.

Enter the date when the fifth target behavior for reduction was identified.

Provide a detailed description of the fifth behavior targeted for reduction.

State the specific goal for the fifth behavior targeted for reduction.

Describe the current level of functioning associated with the fifth behavior.

Enter the target date for the completion of the fifth behavior reduction goal.

Provide the status of the fifth behavior goal at the time of the six-month re-evaluation, including progress and recommendations.

Provide the date when the fifth target behavior was identified.

Describe the fifth target behavior to be increased.

State the specific goal for the fifth target behavior.

Describe the current level of functioning related to the fifth target behavior.

Provide the target date for completion of the fifth behavior goal.

Describe the status of the fifth behavior goal at the time of the 6-month re-evaluation.

Enter the name of the provider who ordered the fifth medication.

Enter the name of the fifth medication.

Enter the dosage of the fifth medication.

Enter the date when the fifth medication was started or stopped.

Describe the patient's response to the fifth medication treatment.

Document any additions, deletions, or changes to the fifth medication record during the 6-month re-evaluation.

Indicate whether the fifth provider, Mental Health Provider, was contacted.

Describe the discussion with the fifth provider, Mental Health Provider.

Enter the 6-month update discussion date with the fifth provider, Mental Health Provider.

Enter the code for the fifth service.

Enter a description for the fifth service.

Enter the frequency of the fifth service.

Enter the units for the fifth service.

Enter the name of the first ABA provider.

Enter the start date when the first ABA provider began services.

Enter the end date when the first ABA provider concluded services, if applicable.

Provide the date when the first target behavior was identified.

Describe the first target behavior identified for the individual.

State the specific goal set for the first target behavior.

Describe the individual's current level of functioning related to the first target behavior.

Provide the target date for the completion of the first behavior's goal.

Provide the status of the first behavior's goals at the time of the 6-month re-evaluation.

Enter the date when this first target behavior was identified.

Describe the first target behavior that is targeted for reduction, for example, "Bolting from caregiver".

Describe the specific goal for the first target behavior, such as "Stay with caregiver 100% of time when requested".

Describe the current level of functioning related to the first target behavior, for example, "Bolts 50% of time from caregiver when in public".

Enter the target date for the completion of the first behavior's goal.

Provide the status of the first behavior's goal at the 6-month re-evaluation, including achievement percentage and any continuing plans or new target dates.

Enter the date when the first behavior target was identified.

Provide a description of the first behavior targeted for increase.

Describe the specific goal for the first behavior target.

Indicate the current level of functioning related to the first behavior target.

Enter the target date for completion of the first behavior target goal.

Provide the status of the first behavior target goal at the 6-month re-evaluation.

Enter the date when the first target behavior was identified.

Provide a description of the first behavior targeted for reduction.

Enter the specific goal for reducing the first targeted behavior.

Describe the current level of functioning related to the first targeted behavior.

Enter the target date by which the first behavior goal is expected to be completed.

Provide the status of the goals for the first behavior at the six-month re-evaluation.

Provide the name of the provider who ordered the first medication.

Provide the name of the first medication.

Provide the dosage for the first medication.

Provide the date when the first medication was started or stopped.

Provide the patient's response to the first medication treatment.

Provide any additions, deletions, or changes made to the first medication during the six-month re-evaluation period.

Enter whether the first occupational therapist has been contacted regarding the patient's treatment.

Provide details of the discussion with the first occupational therapist regarding the patient's treatment.

Enter the date of the 6-month update discussion with the first occupational therapist.

Provide the code for the first service.

Provide a description of the first service.

Provide the frequency of the first service.

Provide the units for the first service.

Provide the full name of the first treatment provider.

Specify the discipline or specialty of the first treatment provider.

Describe the role of the first treatment provider in the treatment.

Indicate the site where the first treatment provider delivers services.

Enter the date when the fourth target behavior was identified.

Describe the fourth behavior that is being targeted for increase.

State the goal for the fourth targeted behavior.

Enter the target date for the completion of the fourth behavior's goal.

Provide the status of the fourth behavior's goals at the time of the six-month re-evaluation.

Enter the date when the fourth target behavior for reduction was identified.

Provide a detailed description of the fourth behavior targeted for reduction.

Specify the goal for the fourth behavior targeted for reduction.

Enter the target date for the completion of the fourth behavior's reduction goal.

Describe the status of the fourth behavior's reduction goal at the time of the 6-month re-evaluation.

Enter the date when the fourth target behavior was identified.

Enter a description of the fourth behavior targeted for increase.

Enter the specific goal for the fourth behavior.

Enter the target date for completion of the fourth behavior's goal.

Enter the status of the fourth behavior's goal at the 6-month re-evaluation.

Enter the date when the fourth target behavior was identified.

Enter the specific fourth behavior targeted for reduction.

Enter the specific goal for reducing the fourth behavior.

Enter the target date for the completion of the goal for the fourth behavior.

Enter the status of the goals for the fourth behavior at the time of the six-month re-evaluation.

Enter the name of the provider who ordered the fourth medication.

Enter the name of the fourth medication.

Enter the dosage of the fourth medication.

Enter the date when the fourth medication was started or stopped.

Enter the patient's response to the fourth medication treatment.

Provide details about any addition, deletion, or change to the fourth medication during the last six months for the 6-month re-evaluation.

Indicate if the fourth primary care physician was contacted.

Provide details about the discussion with the fourth primary care physician.

Enter the date and details of the 6-month update discussion with the fourth primary care physician.

Enter the code for the fourth service being provided.

Provide a description for the fourth service being provided.

Specify the frequency of the fourth service being provided.

Indicate the units for the fourth service being provided.

Provide the name of the fourth treatment provider.

Indicate the discipline or specialty of the fourth treatment provider.

Describe the role of the fourth treatment provider in the treatment.

Specify the site where the fourth treatment provider's services are rendered.

Check this box if the provider performing or supervising the service is contracted.

Check this box if the provider performing or supervising the service is non-contracted.

Check this box if a comprehensive diagnostic evaluation has been completed and attached.

Check this box if a comprehensive diagnostic evaluation has not been completed.

Check this box if the patient is currently receiving Early Intervention Services.

Check this box if the patient is not currently receiving Early Intervention Services.

Check this box if Early Intervention Services are not applicable for the patient.

Check this box if the parent or legal guardian will be present at all treatment visits.

Check this box if the parent or legal guardian will not be present at all treatment visits.

Check this box if the question regarding the parent or legal guardian's presence at treatment visits is not applicable.

Check this box if the patient has been evaluated by a school.

Check this box if the patient has not been evaluated by a school.

Check this box if the patient is currently receiving services from a school.

Check this box if the patient is not currently receiving services from a school.

Check this box if the child is not attending school and a transition goal is in place.

Check this box if the child is not attending school and there is no transition goal in place.

Check this box if the patient has had a medication consultation in the past six months as part of the initial assessment.

Check this box if the patient has not had a medication consultation in the past six months as part of the initial assessment.

Enter the name of the person or entity who conducted the initial medication consultation, if applicable.

Check this box if the patient is currently receiving medication as part of the initial assessment.

Describe the special services the patient is currently receiving at school and/or in the community, including days and hours of services, if applicable.

Enter the member's date of birth.

Enter the full name of the member.

Enter the member's identification number.

Enter the member's current age in years.

Enter the member's definitive diagnosis.

Enter a description of the parent or caregiver training and their participation in treatment sessions.

Enter a description of the parent or caregiver training and their participation in treatment sessions on the 6-month re-evaluation.

Enter the name of the patient's physician treating Autism Spectrum Disorders (ASDs).

Enter the number of times you have met with the patient.

Enter the date of the most recent contact with the patient.

Provide the reason why the patient has not been evaluated by a school.

Enter the number of hours per day or week the patient is receiving services from a school.

Describe the transition goal if the child is not attending school.

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

Enter the Tax ID number for the provider.

Enter the primary phone number for the provider.

Enter an additional phone number for the provider, if applicable.

Enter the street address for the provider's mailing address.

Enter the city for the provider's mailing address.

Enter the state for the provider's mailing address.

Enter the zip code for the provider's mailing address.

Enter the date the initial request was made.

Enter the date of the six month reassessment.

Enter the name of the second ABA provider.

Enter the start date for the second ABA provider.

Enter the end date for the second ABA provider, if applicable.

Enter the date when the second target behavior was identified.

Describe the second behavior targeted for reduction.

Enter the specific goal for the second behavior targeted for reduction.

Describe the current level of functioning for the individual concerning the second behavior.

Enter the target date by which the goal for the second behavior should be completed.

Provide the status of the goal for the second behavior at the time of the 6-month re-evaluation.

Enter the date when the second behavior target was identified.

Enter the specific behavior being targeted for the second goal.

Enter the specific goal set for the second targeted behavior.

Enter the current level of functioning related to the second targeted behavior.

Enter the target date for completion of the second behavior goal.

Enter the status of the second behavior goal at the time of the six-month re-evaluation.

Enter the date when the second behavior targeted for reduction was identified.

Provide a description of the second specific behavior that is targeted for reduction.

Specify the measurable goal for the second targeted behavior.

Describe the patient's current level of functioning related to the second targeted behavior.

Enter the target date for the completion of the intervention for the second targeted behavior.

Provide the status of the goals for the second targeted behavior at the time of the 6-month re-evaluation.

Enter the name of the healthcare provider who ordered this second medication.

Specify the name of this second medication.

Provide the dosage instructions for this second medication.

Indicate when this second medication was started and/or stopped.

Describe the patient's response to the treatment with this second medication.

Document any additions, deletions, or changes regarding this second medication during the 6-month re-evaluation.

Indicate whether the Physical Therapist was contacted.

Provide details of the discussion with the Physical Therapist.

Enter the date and details of the six-month update discussion with the Physical Therapist.

Enter the code for the second service.

Enter a description for the second service.

Enter the frequency of the second service.

Enter the units for the second service.

Enter the name of the second treatment provider.

Enter the discipline or specialty of the second treatment provider.

Enter the role of the second treatment provider in the treatment.

Enter the site where the second treatment provider's services are rendered.

Enter the code for the seventh service being requested.

Enter a description of the seventh service being requested.

Enter the frequency of the seventh service.

Enter the units for the seventh service.

Provide the name of the individual or entity who performed the medication consultation within the past six months.

Check this box if the patient is not currently receiving any medication as part of the six-month reassessment.

Check this box if it is unknown whether the patient is currently receiving medication as part of the six-month reassessment.

Provide details on the special services the patient is receiving at school or in the community during the six-month re-evaluation, including days and hours of services if applicable.

Indicate if the sixth other provider was contacted.

Describe the discussion details with the sixth other provider.

Provide details of the 6-month update discussion or the date it occurred with the sixth other provider.

Enter the code for the sixth service.

Provide a description for the sixth service.

Enter the frequency of the sixth service.

Enter the units for the sixth service.

Enter the name of the third Applied Behavior Analysis (ABA) provider.

Enter the start date of services with the third Applied Behavior Analysis (ABA) provider.

Enter the date when the third target behavior was identified.

Provide a description of the third behavior targeted for increase.

State the goal for the third behavior targeted for increase.

Describe the current level of functioning related to the third behavior.

Enter the target date for completion of the third behavior's goal.

Provide the status of the third behavior's goals at the time of the six-month re-evaluation.

Enter the date when the third target behavior for reduction was identified.

Provide a description of the third behavior targeted for reduction.

Describe the specific goal for the third behavior targeted for reduction.

State the current level of functioning related to the third behavior targeted for reduction.

Enter the target date for the completion of the goal for the third behavior targeted for reduction.

Provide the status of the goals for the third behavior at the time of the six-month re-evaluation.

Enter the date when the third target behavior was identified.

Enter a description of the third behavior being targeted for increase.

Enter the specific goal for the third targeted behavior.

Enter the current level of functioning for the third targeted behavior.

Enter the target date for the completion of the third behavior target.

Enter the status of the third behavior target's goals at the time of the 6-month re-evaluation.

Enter the date the third target behavior was identified.

Enter the specific behavior targeted for reduction in the third row.

Enter the specific goal for the third behavior targeted for reduction.

Enter the current level of functioning for the third behavior targeted for reduction.

Enter the target date for completion of the third behavior reduction goal.

Enter the status of the goals at the time of the six-month re-evaluation for the third behavior.

Enter the provider ordering the third medication.

Enter the name of the third medication.

Enter the dosage for the third medication.

Enter the date when the third medication was started or stopped.

Describe the patient's response to the third medication treatment.

Enter any additions, deletions, or changes to the third medication during the 6-month re-evaluation in the last six months.

Enter whether the third provider, a Speech Therapist, was contacted regarding the patient's treatment.

Provide details of the discussion held with the third provider, a Speech Therapist, regarding the patient's treatment.

Provide the date or details of the 6-month update discussion with the third provider, a Speech Therapist.

Enter the code for the third service.

Provide a description for the third service.

Specify the frequency for the third service.

Indicate the units used for the third service.

Enter the name of the third treatment provider.

Enter the discipline or specialty of the third treatment provider.

Enter the role of the third treatment provider in the treatment.

Enter the site where the third treatment provider provides services.