Medi-Cal
P.O. BOX 11033, ORANGE, CA 92856 Phone: 855-877-3885
Behavioral Health Treatment-Authorization Request Form (BHT-ARF)
(This form is for BHT services only)
Behavioral Health Fax: 714-954-2300
*** IN ORDER TO PROCESS YOUR REQUEST, BHT-ARF MUST BE COMPLETE AND LEGIBLE ***
PROVIDER: Authorization does not guarantee payment. ELIGIBILITY must be verified at the time services are
rendered.
MEMBER INFORMATION
Member Name (Last, First): Sex: M F Other:
Age: DOB: Client Index # (CIN): ICD-10 Dx:
Mailing Address: Phone:
PROVIDER INFORMATION
ABA Provider:
Provider NPI: TIN: Medi-Cal ID:
Address: Phone: Fax:
Office Contact: Provider’s Signature:
AUTHORIZATION REQUEST
List ALL procedures requested along with the appropriate CPT/HCPCS Code(s). Supporting documentation to
include:
▪ Functional Behavior Assessment Report
▪ Treatment Plan/Progress Report
▪ Developmental and Diagnostic Evaluation
▪ PCP, Local Education Agency, ST/OT/PT Communications
REQUESTED PROCEDURES HCPCS CODE UNITS AND
DURATION
(typically 6 months)
Mental health assessment by non-physician H0031
Mental health service plan development by non-physician (Non-BCBA) H0032-HN
Mental health service plan development by non-physician (BCBA) H0032-HO
Skills training and development H2014
Therapeutic behavioral services H2019
Home care training to home care client S5108
Home care training, family S5110
Other
07-23-2020
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