(ABA) Treatment Request for a Functional Assessment Form 2026

1. Click ‘Get Form’ to open the (ABA) Treatment Request for a Functional Assessment Form in the editor.
2. Begin by filling out the 'Member Information' section. Clearly enter the patient's name, legal guardian's name, date of birth, and Medicaid/health plan number.
3. Next, move to the 'Provider Information' section. Indicate whether your group/agency is in-network, out-of-network, or in the credentialing process. Fill in your provider name and select your credential from the options provided.
4. Complete the 'Assessment and Clinical Documentation Requirements' by ensuring all necessary clinical information is included. This is crucial for medical necessity determination.
5. In the 'Treatment Request' section, specify ABA services needed, including behavior identification assessment details such as units and CPT code.
6. Finally, add any comments or additional information if necessary. Don’t forget to sign and date at the bottom of the form to confirm that all information is accurate.

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