Applied Behavioral Analysis (ABA) Prior Authorization Form (New Hampshire) Completed Form Examples and Samples

**Client:** Emily R. Thompson, DOB: 05/12/2018, Member ID: ETR051218ABA.
**Date of Note:** October 26, 2025

**Session Summary & Progress Update:**
Emily continues to make significant progress in her ABA program. This marks our 28th session with her since her initial assessment, and the most recent contact was just last week, October 19, 2025. Her primary diagnosis remains F84.0, Autism Spectrum Disorder. She resides at 145 Pine Street, Manchester, NH 03101, and her guardian can be reached at (603) 555-1234.

We are preparing to submit for continued services, covering a 6-month period from November 15, 2025, to May 14, 2026. This authorization request will require pages 1-6.

**Provider Details:**
Services are provided by Bright Futures ABA Services, NPI: 1234567890. Our main office is located at 200 Elm Street, Suite 101, Nashua, NH 03060. Our Tax ID is 98-7654321, and our fax number is (603) 555-9876.
The supervising BCBA is Dr. Sarah J. Lee, BCBA-D, NPI: 0987654321, License # NH-BCBA-12345.
For any questions regarding this authorization, please contact our administrative assistant, Lisa Chen, at (603) 555-4321.

**Requested Services (for 6-month period, New Hampshire Medicaid):**
*   **97153 (Adaptive behaviors treatment by technician):** We anticipate needing 768 units (approx. 32 hours/month).
*   **97155 (Adaptive behaviors treatment with protocol administered by BCBA):** This will be 144 units (approx. 6 hours/month).
*   **97156 (Family adaptive behavior treatment guidance):** We project 48 units (approx. 2 hours/month) for parent training.

**Coordination of Care:**
Emily receives special education services at Maplewood Elementary (IEP in place). We regularly coordinate with Ms. Davis, her special education teacher. We also communicate with Dr. Mark Greene, her pediatrician, for medical updates. Dr. Greene's last communication with us was on September 20, 2025, discussing Emily's overall health and recent developmental milestones. Emily also sees an Occupational Therapist, Ms. Jessica Stone, for fine motor skills. We last coordinated with Ms. Stone on October 10, 2025, regarding sensory integration strategies.

**Parent/Guardian Participation:**
Emily's mother, Mrs. Thompson, actively participates in all parent training sessions, implements home-based strategies consistently, and practices generalization skills with Emily during daily routines, leading to improved consistency across environments.

**Medication Review:**
Emily is currently taking Risperidone. Dosage: 0.5 mg, once daily. This medication was prescribed by Dr. Lena Patel, a pediatric psychiatrist. She has been on this for 6 months with good response for managing irritability. Her last medication consultation with Dr. Patel was on October 1, 2025.

**Treatment Goals (for continued services):**
1.  **Behavior:** Increase functional communication (requesting). **Identified:** 08/15/2025. **Goal:** Emily will initiate requests for preferred items/activities using 3-word phrases in 80% of opportunities across 3 different therapists. **Current:** Initiates 2-word requests in 50% of opportunities. **Target Completion:** 02/15/2026.
2.  **Behavior:** Reduce elopement from task/area. **Identified:** 08/15/2025. **Goal:** Emily will remain seated and engaged for 10-minute intervals without elopement in 90% of opportunities. **Current:** Elopes once every 5-7 minutes. **Target Completion:** 03/15/2026.
3.  **Behavior:** Increase independent play. **Identified:** 09/01/2025. **Goal:** Emily will engage in independent play with preferred toys for 15 minutes, 3 times per session. **Current:** 5 minutes, 1-2 times per session. **Target Completion:** 04/01/2026.