Request for Authorization for Applied Behavior Analysis (ABA) Services Completed Form Examples and Samples

Patient: Leo Thompson, DOB: 05/12/2021. Member ID: A-88921-X. Current diagnosis: F84.0 (Autism Spectrum Disorder), as diagnosed by Dr. Sarah Jenkins, PhD. Leo resides in California and will receive all services in the same state. His mother, Maria Thompson, is the primary caregiver (555-019-2834, [email protected]). We are requesting a Comprehensive ABA program starting 03/01/2026. Leo first began ABA interventions at age 3. The agency, 'Bright Horizons Behavior Health', holds Tax ID 99-8765432 and NPI 1234567890. We are in-network with the local Blue plan. Our service center is located at 123 Maple Lane, San Francisco, CA 94102. Contact person is Mark Stevens (415-555-9988, [email protected]). Voicemail at the agency and for our lead BCBA, Elena Rodriguez (NPI: 0987654321, TID: 99-0001111), is strictly confidential. Fax approval requests to 415-555-7766. For the authorization period, we request: 8 units of CPT 97151 (Behavior Identification Assessment), 4 units of 97153 per week (Adaptive Behavior Treatment), 2 units of 97156 (Family Guidance) per week, and 1 unit of 97155 (Protocol Modification) per week. Elena Rodriguez, BCBA (License #BCBA-98765) has signed this plan on 02/15/2026. Dr. Alan Grant, MD (License #MD-11223) confirmed his coordination of care on 02/16/2026.