A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
749120.1118
Applied Behavior Analysis (ABA)
Clinical Service Request Form
(Page 1 of 5)
Check one:
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Initial Request
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Concurrent Request
For any questions, call BCBSTX at 800-528-7264 or BCBSTX FEP at 800-528-7264 Fax Forms to 877-361-7646
1) For the Initial Treatment Request (ITR)
Submit: Completed Clinical Service Request Form (pages 1-5), Diagnostic Evaluation Report, Provider Baseline and Skills Assessment
Instruments and Comprehensive Treatment Plan (additional information may be requested by a clinician once the case is reviewed)
2) For the Concurrent Treatment Request (CCR)
Submit: Completed Clinical Service Request Form (pages 1-5), Skills Re-Assessment Report and Comprehensive Treatment Plan
(additional information may be requested by a clinician once the case is reviewed)
PATIENT INFO
Patient Name __________________________________________________ Patient Date of Birth _______________ Today’s Date _____________________
Subscriber Name _______________________________________________ Subscriber ID _________________________ Group ______________________
Patient resides in what state? __________________________ Services conducted in same state?
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Yes
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No If no, what state? ____________________
DIAGNOSTIC PRACTITIONER INFO
Diagnostic Practitioner Name _____________________________________________________________________ NPI ______________________________
Diagnostic Practitioner Type, if PCP:
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Family Practice
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Internal Medicine
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Pediatrics
Diagnostic Practitioner Type, if Specialized ASD-Diagnosing Provider:
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Developmental Behavioral Pediatrics
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Neurodevelopmental Pediatrics
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Child Neurology
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Adult or Child Psychiatry
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Licensed Clinical Psychology
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Other (specify) _______________________________________________
Primary Diagnosis Code ________ Secondary Diagnosis Code __________ Dates of Evaluations: Initial _________________ Follow Up ________________
BCBA, BCBA-D, PROFESSIONALLY LICENSED PRACTITIONER INFO
ABA/Team Supervisor Name ______________________________________________________________ License/Cert # _____________________________
Team Supervisor Certification and /or License (check what applies):
Certified through the Behavior Analyst Certification Board (BACB):
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BCBA
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BCBA-D
Professional Licensed Practitioners (minimum of six months specialized training):
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Licensed Clinical Psychology (PhD)
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Other Licensure ____________
Master’s level clinician/state-recognized professional credential or certification _______________________________________ State __________________
CERTIFICATION OF DX & TREATMENT EXPECTATION
I,
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Diagnostic Practitioner or
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ABA Services Supervisor (having confirmed with the diagnostician), am recommending ABA services and certify
there is a reasonable expectation that this member can actively participate and demonstrates the capacity to learn and develop generalized skills to
assist in his/her independence and functional improvements.
Line Therapist
Requirements
ABA Supervisor
Requirements
Requirements for line staff providing 1:1 therapy: 1) 18+ years of age; 2) High school diploma or GED; 3) criminal
background check prior to active employment; 4) via practice expense, completed training of ASD & behavioral
related subjects/evidence based techniques (40 hours) and 5) have on-going supervisory oversight by the BCBA or
ABA treatment supervisor for a minimum of 5% of hours directly worked with members.
As the ABA Supervisor (above), I attest that I follow outlined guidelines for supervision by the BACB and have an
active license in the state where this member’s services are rendered.
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Yes
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No
CERTIFICATION OF PROVIDER QUALIFICATIONS
By signing and returning this form to Blue Cross and Blue Shield, I hereby certify: (1) credentials/license as noted above; (2) the line therapists for
whom I, or an outpatient mental health agency or clinic, will bill meet the qualifications set forth above; (3) if staff changes at any time, new staff must
meet the same qualifications; (4) time spent meeting the training requirements are not billable to BCBS or BCBS’s members and (5) BCBS may,
in its discretion, review its claim history or request supporting information in order to verify the accuracy of this certification.
ABA Supervisor Signature __________________________________________________________ Date __________________________________________
ABA Supervisor Printed Name _______________________________________________________ Clinic Name ____________________________________
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