Phone: 602- 263-3000 or 800-624-3879
Fax: 800-217-9345
Applied Behavior Analysis (ABA) Services Prior Authorization Request Form
Request completed by: ___________________ _______Phone #: Fax #: ____________ ___________
Date of Request: _______________ _________ Total Number of Pages: ____________________ ____
Authorization on File (check one): Yes No _ ____ ___ If Yes, Date of Last Scheduled Visit: __________ _______
Is the member diagnosed with Autism Spectrum Disorder (ASD) (check one) – F84.0? Yes No _____
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• If not, what is the
current diagnosis code(s):
Member Information
Member Name: Member ID #: DOB:
Other Insurance(check one):Yes No If yes ple
ase specify:
Phone #:
Behavioral Hea
lth Home
Provider Name:
Address:
Phone #: Fax #:
Member receiving High Needs Case Management(check one): Yes No
Contact N
ame and Phone
#:
Rendering Service Provider Information
Provider Name: TIN/NPI#:
________________________________
____
_____________________________
_____________________________________________________________________________
________________________________________
____ ____ ____ ____ _______________
Address:
Phone #: Fax #:
C
redentials for provider delivering clinical direction and supervision:
BCBA BCBA-D LBA Behavior Health P
rofessional Other (specify):
Assessment & Treatment
ABA Therapy being requested (required)(check on
e): Focused or Comprehensive ______ ____ _
Please ensure the f
ollowing has been included in your request:
• Assessment findings:
a. Brief description of assessments, including their purpose;
• Indirect Assessments: Summary of findings for each assessment (graphs, tables, or grids);
• Direct Assessments: Summary of findings for each assessment (graphs, tables or grids);
b. Target behaviors are operationally defined, including baseline levels;
c. Functional Behavior Assessment, if applicable.
• Individualized Treatment plan should include the f ollowing:
- Treatment setting and mod
ality by which service wil l be delivered (in-person, via telehealth, group,
individualized setting, or combination thereof);
- Operational definition of each behavior/goal/skill;
1
Proprietary
