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(ABA) Treatment Request for a Functional Assessment Form

(ABA) Treatment Request for a Functional Assessment Form 2025

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4.5 out of 5

23 votes

The document is a request form for a Functional Assessment related to Applied Behavioral Analysis (ABA) treatment, intended for submission to AmeriHealth Caritas Louisiana's Behavioral Health Utilization Management team. It includes sections for member and provider information, diagnosis details, assessment requirements, and treatment requests. The form emphasizes the need for clear and complete information to avoid processing delays.

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Versions	Form popularity	Fillable & printable
2019	4.8 Satisfied (56 Votes)
2017	4.5 Satisfied (23 Votes)

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