Service Request for Autism Specialty Services
DPH/BFHN/Division of Early Intervention December 12, 2017
Child’s Name: Child’s DPH ID#:
Early Intervention Program:
Insurance Provider: Member ID#:
EI Contact Name: Phone:
(sender/receiver of this form)
Date: _____________ Initials: ___________
Does not include Autism Benefit; no PA required confirmation letter requested/received
Billing to DPH Billing to Mass Health 2
nd
coverage
Autism Benefit included; PA required Yes No
Next Steps: Please notify EI of Assessment date ASAP. *Please do NOT complete Assessment without PA in place.
Date: _____________ Initials: ___________
PA for assessment received
___________ _____ Units/hours approved From _______________ To _______________ PA # _________________
Procedure Code Start date End date
Next Steps: Please send completed treatment plan via secure email or fax at least 2-3 business days prior to requested
start date of services. EI will then obtain PA for ongoing services and notify you of approval status.
*Please do NOT begin services without PA in place.
Date: _____________ Initials: ___________
PA for ongoing services received-details below
___________ _____ Units/hours approved From _______________ To _______________ PA # _________________
Procedure Code Start date End date
___________ _____ Units/hours approved From _______________ To _______________ PA # _________________
Procedure Code Start date End date
___________ _____ Units/hours approved From _______________ To _______________ PA # _________________
Procedure Code Start date End date
___________ _____ Units/hours approved From _______________ To _______________ PA # _________________
Procedure Code Start date End date
___________ _____ Units/hours approved From _______________ To _______________ PA # _________________
Procedure Code Start date End date
Updated Treatment Plan is due to EI program by: ____________________
*This information is based on verification of benefits and is subject to change. Additional information may be required
or new information may be obtained during the Prior Authorization process, if applicable and will be forwarded.
