Get Comprehensive Autism Care Demonstration Service Request

Filling out the Comprehensive Autism Care Demonstration Service Request can seem complex, but following the right steps can simplify the process. This guide provides a clear, step-by-step overview to help you complete the service request accurately and efficiently.

Follow the steps to successfully complete your service request.

1. Click ‘Get Form’ button to access the Comprehensive Autism Care Demonstration Service Request form and open it for editing.
2. Begin by filling out the 'Beneficiary Information' section. Provide the last name, first name, middle initial, address, contact phone number, gender, date of birth, sponsor ID number, and city, state, and ZIP code details.
3. Proceed to the 'Requesting Provider Information' section. Include the provider's name, NPI/TIN number, address, contact details, and city, state, and ZIP code information.
4. Complete the 'Provider Rendering Care (ASD Provider/Autism Agency)' section by providing the name, address, office phone number, and NPI/TIN number of the ASD provider.
5. In the 'Service Request Information' section, specify the diagnosis, ICD-9-CM code, anticipated start date of service, and any relevant dates for continuation of services.
6. Indicate the type of service request such as 'new services,' 'provider change,' or 'change of services.' Ensure to enter any associated notification numbers if applicable.
7. Fill out any specific service needs such as ABA assessment details, CPT codes, units requested, and provider types within the relevant subsections.
8. Review your entries for any missing information or errors, and make necessary corrections.
9. Once completed, you can save changes, download, print, or share the form as needed to submit your request.

Complete your Comprehensive Autism Care Demonstration Service Request online today to ensure timely care.