Get Il Blue Cross Blue Shield Initial Assessment Request 2020-2025

Filling out the IL Blue Cross Blue Shield Initial Assessment Request online is a straightforward process that enables you to provide necessary information for the assessment of applied behavior analysis services. This guide will walk you through the sections of the form, ensuring that you understand what information is required and how to complete each part accurately.

Follow the steps to complete the form effectively.

1. Click ‘Get Form’ button to access the IL Blue Cross Blue Shield Initial Assessment Request form and open it in your document management system.
2. Begin by entering the patient information in the designated fields. This includes the patient's name, date of birth, and request submission date. Make sure to provide the subscriber's name and ID details.
3. Indicate the state in which the patient resides and confirm whether the services will be conducted in the same state. If the answer is 'No', specify the state where the services will be performed.
4. Fill out the diagnostic practitioner information by entering the name, National Provider Identifier (NPI), telephone, and fax numbers. Include the contact name and select the appropriate practitioner type. Provide the primary and secondary diagnosis codes as well.
5. Next, enter the rendering qualified healthcare provider's information. This includes their name, NPI, email, and telephone number. Ensure to provide the clinician's credentials and the name of their practice.
6. In the provider treatment request section, specify the assessment request start and end dates. Indicate the ABA assessment code and total units for the assessment period, also including any additional code requests as necessary.
7. Confirm all information is accurate and complete. The rendering qualified healthcare provider must sign and date the form in the certification section.
8. Once all fields are filled, you can save your changes, download the completed form or print it for mailing or faxing.

Complete your IL Blue Cross Blue Shield Initial Assessment Request form online today!