Follow the steps to complete your Clinical Service Request efficiently.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Indicate the request type by checking either ‘Initial Request’ or ‘Concurrent Request’ at the top of the form. Ensure that you submit the form at least two weeks before the requested start date.
3. Fill out the patient information section thoroughly, including the patient name, date of birth, today's date, subscriber name, subscriber ID, group number, state of residence, and whether services will be conducted in the same state.
4. Provide the diagnostic practitioner information, including their name, NPI, type of diagnostic practitioner, primary and secondary diagnosis codes, and evaluation dates.
5. Enter the provider information by detailing the rendering qualified healthcare provider's name, NPI, email, telephone number, credentials, practice name, and address.
6. In the certification of diagnosis and treatment expectation section, indicate if you are the diagnostic practitioner or the ABA services supervisor, confirming the necessity for ABA services.
7. Complete the provider treatment request section, specifying the current request start date, requested service intensity, total requested hours per week, and ABA procedure code requests.
8. Document the patient’s ABA treatment history, including previous services, average hours per week, and any break in services.
9. Fill out the baseline and assessment info section, ensuring the included assessments and scoring summaries are current.
10. Describe current maladaptive behaviors, providing the frequency of each behavior observed.
11. Outline the member treatment plan, including new goals, goals on hold, and those mastered during the previous authorization period.
12. Indicate the preferred parent involvement and expected measurable parent training goals.
13. Complete the treatment fade/transition/discharge plan, including measurable criteria for the fade plan and discharge objectives.
14. Fill in the member ABA schedule detailing therapy times, locations, and any other relevant treatment schedules.
15. Finally, review all entries for accuracy and completeness. Users can then save changes, download, print, or share the completed form as needed.

Begin filling out your Clinical Service Request online today to ensure timely access to necessary ABA services.