Follow the steps to fill out each section of the form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred online editor.
2. Begin by indicating whether this is an Initial Request or a Concurrent Request by checking the appropriate box.
3. Fill in the Patient Information section with the patient's name, date of birth, today's date, subscriber name, subscriber ID, and group number.
4. Answer the questions regarding the patient's state of residence and whether services will be conducted in that same state.
5. In the Diagnostic Practitioner Information section, enter the diagnostic practitioner's name, NPI number, and type (PCP or specialized ASD-diagnosing provider), including designation if applicable.
6. Provide the Primary and Secondary Diagnosis Codes, as well as the dates of evaluations for the patient.
7. Complete the ABA/Team Supervisor Information by entering the supervisor's name, their license/certification number, and confirming their qualifications.
8. In the Certification of Diagnosis & Treatment Expectation section, select the appropriate professional role and confirm the expectation for the member's participation and progress.
9. Fill out the Provider Information section with facility details, including name, NPI, address, and contact information.
10. Specify the treatment request start date and requested service intensity, noting total hours per week.
11. Enter the ABA procedure codes as needed and any additional codes with the corresponding reasons.
12. Complete the ABA Treatment History section and indicate any past services received by the member along with relevant details.
13. Record current maladaptive behaviors, including frequency and specific details about each behavior.
14. Outline the member treatment plan, setting measurable goals along with current progress and expected mastery dates.
15. Indicate parent involvement and gather information about their expected participation in training sessions.
16. Provide details regarding the treatment fade/transition/discharge plan, including parent agreement.
17. In the final section, fill in the member's schedule for ABA services, including days, times, and coordination with other therapies.
18. Once all sections are complete, review the form for accuracy, then save changes, download, print, or share the completed form as needed.

Complete your IL Blue Cross Blue Shield Clinical Service Request form online today for efficient processing.