Follow the steps to complete the Ongoing Authorization Request Form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Provide the requesting provider information. Fill in the requesting provider’s name, telephone number, fax number, state license number, billing tax ID number, NPI number, and contact name. Verify if the requesting provider is the one performing the service by selecting 'Yes' or 'No'. If they are not, fill out the servicing provider information in the section that follows.
3. Complete the patient information section. Include the sponsor's social security number or DoD benefits number, patient's date of birth, last name, first name, middle initial, home phone number, complete address, city, state, and ZIP code.
4. Enter service setting details, indicating where the services will be provided (home, school, community) and include the most recent Individualized Education Plan if available.
5. Provide the primary and secondary diagnosis codes along with a description of the patient's condition or need for services.
6. Indicate if the patient has other health insurance by selecting 'Yes' or 'No' and fill in the policy number and carrier if applicable.
7. In the requested services section, fill in the anticipated service start date, and indicate the units provided and requested for each applicable CPT code.
8. Confirm whether the beneficiary and family members are willing and able to participate in the ABA treatment plan. If not, provide an explanation.
9. Attest to the accuracy of the information provided by filling in the authorized ABA supervisor name and title, signing, and dating the form.
10. Once the form is completed, users can save changes, download, print, or share the form as needed.

Start filling out the Ongoing Authorization Request Form online today to ensure timely processing of your request.