Applied Behavioral Analysis (ABA) Prior Authorization Request Form (Coordinated Care) Completed Form Examples and Samples

Explore detailed examples of a completed Applied Behavioral Analysis (ABA) Prior Authorization Request Form for Coordinated Care. See how patient, provider, service, and diagnostic information is accurately extracted and filled, demonstrating best practices for ABA prior authorization submissions.

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Filled Applied Behavioral Analysis Prior Authorization Request Form for Coordinated Care

ABA Prior Authorization Request Form (Coordinated Care) Example

How this form was filled:

Our AI efficiently extracted all necessary patient, provider, service, and diagnostic information from detailed clinical progress notes to accurately complete the ABA Prior Authorization Request Form for Coordinated Care, demonstrating its ability to handle complex medical documentation.

Source document used: Clinical Progress Notes

**Patient: Emily Jensen** (DOB: 08/15/2019, Medicaid ID: WA1234567J). Her mother, Mrs. Jensen, confirmed her contact number is (555) 123-4567. Emily continues to make progress in her early intervention program, showing improved social reciprocity.

Today's date is **February 28, 2025**. We are preparing the prior authorization request for her upcoming ABA therapy, which is crucial for maintaining her developmental trajectory.

**Current Medical Status:** Emily's parents report she has mild asthma controlled with an inhaler as needed and seasonal allergies that are well-managed with over-the-counter medication. No new medical concerns were raised during her last check-up with Dr. Davis.
**Medications:** Emily is currently on Risperidone 0.5mg daily for irritability associated with her diagnosis, and Melatonin 3mg at bedtime to assist with sleep regulation. Both medications are prescribed by her pediatrician.

**Behavioral Health History:** Emily has a history of behavioral health treatment, specifically with Dr. Alex Garcia, a pediatric psychologist, who has been providing support for anxiety and behavioral regulation strategies for the past year. Dr. Garcia has reviewed the proposed ABA treatment plan and provided positive feedback, indicating that it aligns with Emily's overall care goals and would be a beneficial adjunct to her current therapeutic supports. The parents, Mr. and Mrs. Jensen, have also reviewed and explicitly agreed to all ABA treatment goals as outlined in her individualized plan, including the focus on communication and adaptive living skills. There is no active psychiatric care currently.
**Coordination of Care:** We have successfully coordinated with Emily's PCP, Dr. Mark Davis, regarding her overall health and the integration of ABA services. No concerns were raised.

**Proposed ABA Services (Start Date: March 10, 2025, End Date: September 10, 2025):** We are requesting 120 units for Procedure Code 97153 (Adaptive Behavior Treatment by protocol), 40 units for Procedure Code 97155 (Adaptive Behavior Treatment by protocol with modification), and 20 units for Procedure Code 97156 (Adaptive Behavior Treatment by group protocol).

**Diagnosis:** Emily's primary diagnosis remains F84.0 (Autism Spectrum Disorder, requiring very substantial support). Secondary diagnosis is F80.2 (Mixed receptive-expressive language disorder), and she also exhibits R48.8 (Other symbolic dysfunctions, speech and language related), specifically dyspraxia. This is an initial authorization request.

**Provider Details:** The services will be rendered by Dr. Sarah Chen, NPI 1234567890, practicing under Bright Futures ABA Center. The facility TIN is 98-7654321. Claims will be submitted under the facility's NPI. Our authorized contact person for these requests is Jessica Lee, our administrative assistant. Our fax number for authorizations is (555) 987-6543.

**Required Attachments for Initial Authorization:** For this initial authorization, we have compiled and will be attaching Emily's Initial Evaluation report, the comprehensive Treatment Plan with Smart Goals, a signed prescription for ABA therapy services, the DSM-5 checklist completed by the assessing psychologist, and the HCA 12-411 form detailing her ABA Level of Support Requirements. All documents are current and meet the 5-day submission requirement before the requested start date.

Information used to fill out the document:

Date: February 28, 2025
Patient Information: Emily Jensen, DOB 08/15/2019, Medicaid WA1234567J, Phone (555) 123-4567
Provider/Facility Information: Dr. Sarah Chen, Bright Futures ABA Center, NPI 1234567890, TIN 98-7654321, Contact Jessica Lee, Fax (555) 987-6543 (Claims under Facility)
Requested Services: 97153 (120 units), 97155 (40 units), 97156 (20 units) from 03/10/2025 to 09/10/2025
Diagnoses: Primary F84.0, Secondary F80.2, Additional R48.8
Current Medications: Risperidone 0.5mg daily, Melatonin 3mg at bedtime
Medical Conditions Reported: Mild asthma, seasonal allergies
Coordination of Care: PCP (Dr. Mark Davis) - Yes; Psychiatrist - No; BH Treatment (Dr. Alex Garcia) - Yes; ABA Reviewed by BH Provider - Yes; Parent/Guardian agrees - Yes
Initial ABA Attached Documents: Initial Evaluation, Treatment Plan with Smart Goals, Signed Prescription, DSM-5 Checklist, HCA 12-411 Form

What this filled form sample shows:

Identified and parsed **multiple service request blocks** with associated procedure codes, units, and start/end dates from a single narrative section.
Extracted **all relevant ICD-10 diagnosis codes** (primary, secondary, and additional) from naturally embedded prose.
Accurately recognized and extracted **patient and provider demographic details** (names, NPI, TIN, Medicaid ID, phone, fax) scattered throughout the clinical notes.
Determined **coordination of care status** with PCP and Behavioral Health (BH) provider, and confirmed parental agreement for ABA treatment goals.
Identified all **required attached documents for an initial authorization**, correctly indicating which checkboxes should be marked based on the document's context.

Form specifications and details:

Use Case:	Initial ABA Prior Authorization Request for a child with Autism Spectrum Disorder
Source Document:	Detailed Clinical Progress Notes
Categories:	prior authorization forms, CAR forms, ABA forms, Coordinated Care forms, authorization forms, ABA authorization forms, L.A. Care forms
Created:	March 10, 2026 07:00 AM