ASD REGISTRATION AUTHORIZATION TEMPLATE Facility 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Facility/Provider Name and the contact person's details, including their name and contact number with extension.
3. Fill in the Member Name along with their Medicaid/Consumer ID# and Date of Birth (DOB).
4. Specify the Request Format, including the Requested Start Date and/or Social Security Number (SSN).
5. Indicate the Requested Units/Hours Per Week for services needed.
6. Select the Location of Services, such as Home, Office, or Community.
7. Identify who is providing the service by selecting from options like BCBA, Licensed Clinician, or Technician.
8. For ABA Assessment Requests, provide a clinical rationale for the request and detail any tools you plan to use.
9. Complete sections for ABA Services Requests by specifying hours per week for each type of therapy required.

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