Bcbstx request 2025

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The document is a Clinical Service Request Form for Applied Behavior Analysis (ABA) services, detailing the process for initial and concurrent treatment requests. It includes sections for patient information, diagnostic practitioner details, provider qualifications, treatment history, assessment information, current maladaptive behaviors, treatment plans, parent involvement, and scheduling. The form requires signatures from diagnostic practitioners and ABA supervisors to certify the need for services and compliance with qualifications.

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Click ‘Get Form’ to open the bcbstx request in the editor.
Begin by selecting whether this is an Initial Request or a Concurrent Request. This choice will guide the subsequent sections you need to complete.
Fill in the Patient Info section, including the patient's name, date of birth, and subscriber details. Ensure accuracy as this information is crucial for processing.
In the Diagnostic Practitioner Info section, provide details about the diagnosing practitioner, including their name and NPI number. Select their type based on your specific situation.
Complete the ABA/Team Supervisor Info section with relevant supervisor details and check applicable certifications.
Proceed to fill out the Treatment Request section, specifying service intensity and total requested hours per week.
Finally, review all entries for accuracy before submitting your completed form through our platform for free.

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