May 2021

New Applied Behavior Analysis (ABA) Service Request Forms

As of March 2021, we’ve updated our ABA service request forms to streamline data required for review. To request services:

• Download and fill out the appropriate form:
• Initial Assessment Request
• Clinical Service Request for initial and concurrent treatment requests
• Be sure to include the contact information and signature of the rendering Qualified Healthcare Provider (QHP) who is providing treatment.
• Fax the completed form to 877-361-7660 at least two weeks before the requested start date.

If we don’t receive the form within 30 days of the start date, you will need to submit claims through your normal process.

Questions? Call us at 800-672-2378.
Find other forms under Education and Reference.