Place of Service Last Name Phone Third Party Insurance Yes Medicaid New York 1-855-713-0591 11- Office 12- Home 22- Outpatient Hospital 53- Community Mental Health Center Other (provide code)- No First Name, Middle Initial MEMBER INFORMATION Date of Birth WellCare ID Gender Male Female If Yes, please attach a copy of the insurance card. If the card is not available, provide the name of the insurer, policy type, and number. Languages Spoken TREATING PROVIDER/PRACTITIONER INFORMATION Last Name First Name NPI WellCare ID Street Address Phone Participating Yes No Discipline/Specialty City, State Fax FACILITY/AGENCY INFORMATION Office Contact Name Facility ID NPI Street Address Phone City, State Fax Office Contact BOARD CERTIFIED BEHAVIOR ANALYST INFORMATION For ABA serv ices: Is provider certified to prov ide ABA consistent services as defined by state s licensing requirements? ZIP ZIP No Yes N/A per state s licensing requirements Hav e ABA serv ices been ordered by a board-certified psychiatrist, psychologist or pediatrician qualified to prov ide ABA oversight? No Yes: include copy of BCBA Order Name of BCBA professional who will superv ise services: BCBA certification #: Degree/License: Service Type Requested Applied Behav ior Analysis REQUESTED SERVICES List CPT Code(s) of Units of Each CPT Code Requested
Serv ice Request Start Date: DIAGNOSIS The follow ing are mandatory fields. ABA service requests w ill not be processed if the diagnostic section is not fully completed. Diagnosis Information Assessment Information When was the Autism Spectrum diagnosis established? Date: When did the most recent assessment occur? By whom?(include full name and credentials) Current IQ lev el: DSM or ICD Diagnosis With or without accompanying intellectual impairment With or without accompanying language impairment Associated with a known medical or genetic condition or env ironmental factor With catatonia Primary Members who are < 18 years old must hav e a diagnosis of one of the following: (Lev el 1, Lev el 2, or Lev el 3) Social (Pragmatic) Communication Disorder Or, a prev ious DSM IV diagnosis of one of the following: o Asperger s Disorder (Asperger Syndrome) o Perv asive Developmental Disorder, not otherwise specified o Childhood Disintegrativ e Disorder (CDD) o Rett Disorder (Rett Syndrome) Psychosocial Barrier, if applicable: Secondary Co-occurring Diagnosis, if applicable: Medical Summary of function capacities and areas of impairment RATIONALE FOR REQUEST AND TREATMENT HISTORY Assessment and clinical tool(s) used for diagnosis (i.e., BLA, Preference Assessment, FBA, ABLL S-R, VB-MAPP) Biopsychosocial summary including household members, env ironmental factors and medical issues, current educational situation and school serv ices What type of treatment components will be prov ided?
Current Psychotropic Medications (if applicable): Medication Name: Dosage: Please explain the current treatment modalities and serv ices in place: Area of Concern #1 Behav ior/deficit to Decrease TREATMENT PLAN (attach baseline lev el data for each area of concern) Behav ior/skill to Increase Methods to be used Goals and skills of parent/guardian Objective criteria for attainment of goal Target date for introduction of goal Attainment date of goal Care coordination needs
Interv entions emphasizing generalization of skills and focus on the dev elopment of spontaneous social communication, adaptive skills and appropriate behav iors Area of Concern # 2 Behav ior/deficit to Decrease (attach baseline level data for each area of concern) Behav ior/skill to Increase Methods to be used Goals and skills of parent/guardian Objective criteria for attainment of goal Target date for introduction of goal Attainment date of goal Care coordination needs Interv entions emphasizing generalization of skills and focus on the dev elopment of spontaneous social communication, adaptive skills and appropriate behav iors Area of Concern # 3 Behav ior/deficit to Decrease (attach baseline level data for each area of concern) Behav ior/skill to Increase
Methods to be used Goals and skills of parent/guardian Objective criteria for attainment of goal Target date for introduction of goal Attainment date of goal Care coordination needs Interv entions emphasizing generalization of skills and focus on the dev elopment of spontaneous social communication, adaptive skills and appropriate behav iors Is the child: Attach additional pages if necessary to identify other areas of concern TRANSITION PLAN Beginning treatment Transitioning from a home-based intensiv e ABA-based program to a lesser lev el of care Transitioning from a most to least restrictiv e setting Transitioning from a home-based ABA interv ention program to a school-based program Projected transition plan/goals: If clinically necessary, what are the prev ention plan and/or resolution of crises? (i.e., behavior, consequences, antecedents, de-escalation procedures, prev ention, baseline) Is there a crisis plan in place? No Yes: What is it? How will member transition into adulthood? Projected criteria for discharge:
Expected discharge date: Next lev el of care: