Aba-request-for-a-functional-assessment-form 2025

1. Click ‘Get Form’ to open the aba-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 provider names and credentials for each listed provider.
4. Complete the 'Physical Address', 'Phone Number', and 'Medicaid/Provider/NPI #' fields accurately to ensure proper communication.
5. In the 'Assessment and Clinical Documentation Requirements' section, ensure you have all necessary clinical information ready for submission.
6. Fill out the treatment request details including ABA services needed, behavior identification assessment units, CPT code (97151), and time frame (weekly/monthly).
7. Add any comments or additional information that may be relevant before signing at the bottom of the form.

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