Applied Behavior Analysis (ABA)
Initial Assessment Request
For any questions, call BCBSTX at 800-528-7264 or BCBSTX FEP at 800-528-7264. Fax Forms to 877-361-7646.
PATIENT INFO
Patient Name _____________________________________________ Patient Date of Birth _______________ Request Submission Date _______________
Subscriber Name _____________________________________________ Subscriber ID _________________________ Group _______________________
Patient resides in what state? _________________ Services conducted in same state?
Yes
No If no, what state? __________________________
DIAGNOSTIC PRACTITIONER INFO
Diagnostic Practitioner Name ________________________________________________________________ NPI __________________________________
Telephone ______________________________ Fax ________________________ Contact Name _______________________________________
Diagnostic Practitioner Type, if PCP:
Family Practice
Internal Medicine
Pediatrics
Diagnostic Practitioner Type, if Specialized ASD-Diagnosing Provider:
Developmental Behavioral Pediatrics
Neurodevelopmental Pediatrics
Child Neurology
Adult or Child Psychiatry
Licensed Clinical Psychology
Other (specify) _______________________________________________
Primary Diagnosis Code ________ Secondary Diagnosis Code __________ Dates of Initial Evaluations _______ / ________ / __________
AUTHORIZATION/COMMUNICATION SENT TO
Facility Name ____________________________________________________________________ NPI ___________________________________________
Address _________________________________________________________ City ________________________ State ________ Zip Code ___________
Telephone _______________________ ext ________ Fax __________________________ Contact Name _______________________________________
BCBA Name ________________________________________________________ NPI _______________________ License/Cert _____________________
Address (if not same as above) _______________________________________________ City _________________ State _____ Zip Code ______________
Telephone _______________________ ext ________ Fax ___________________________ Contact Name ______________________________________
PROVIDER REQUEST
Assessment Request Start Date ________ / _________ / __________ to End Date ________ / _________ / __________
ABA Assessment Code Request
(Total Units for Assessment Period;
1 Unit = 15 minutes)
CERTIFICATION OF PROVIDER QUALIFICATIONS
ABA Supervisor Signature _______________________________________________________ Date ________ / ________ / ________
ABA Supervisor Printed Name ____________________________________________________ Clinic Name _________________________________
97151 97152
QHP Technician
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
749121.1118
Additional Code(s) Request and Reason
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signature
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