Applied Behavior Analysis (ABA)
Prior Authorization Form
In the hope to save you, our provider, some time on the phone, we invite you to fill out this form for ABA treatment
requests. In filling out this form, you are doing so in lieu of the telephonic clinical review. This form should be completed
by a provider who has a thorough knowledge of the Cigna customer's current clinical presentation and his/her treatment
history. Please note: The information contained in this form may be released to the customer or the customer's representative.
Please save this form to your computer, complete & save the form using Adobe Acrobat Reader DC, then email it to:
ABA@Cigna.com* (preferred) or fax 1.860.687.9230
TIPS FOR COMPLETING THIS FORM:
Our regular business hours are Monday – Friday, from 7:30am – 5:00pm Central Time
To help expedite this request, please complete sections as specifically and as clearly as possible. Omissions,
generalities, and illegibility may result in this request being returned for additional information or clarification
Typed responses are preferred. If completing by hand, please use blue or black ink and print legibly.
If you have any questions, call ABA Scheduling at 1.877.279.7603
Customer Name: Member ID:
928213b Rev. 02/2020 Page 1 of 4
All fields are required.
Date of Birth
M M D D
Y Y Y Y
If treatment plan is referenced for response, please indicate page number.
Is the customer diagnosed with Autism Spectrum Disorder (ASD): Yes No
Date of most current diagnostic evaluation and evaluator's name/credentials:
List any current medications:
Supervising Provider's Name:
Please list the best times our team could contact you within the next five business days for questions, concerns,
or determination information:
Clinic Name: Clinic Contact (if different from provider):
The form below is based on our Medical Necessity Criteria for ABA. Please find the detailed criteria online at:
Is Voicemail confidential?
If No, what is the current diagnosis (please include diagnosis and diagnostic code).
* Please note that Cigna assumes no responsibility for the protection of electronically transmitted information prior to its actual
receipt of that information. It is your responsibility to take any steps necessary to protect the email or documents prior to receipt by