Get Tx Bcbs Form 749120.1118

This guide provides clear and supportive instructions for completing the TX BCBS Form 749120.1118 online. Follow these steps to ensure accurate and efficient submission of your clinical service request.

Follow the steps to successfully complete your form.

1. Press the ‘Get Form’ button to access the TX BCBS Form 749120.1118 online and open it in the editor.
2. Select whether you are making an Initial Request or a Concurrent Request by checking the appropriate box at the top of the form.
3. Fill out the patient information section by providing the patient’s name, date of birth, today’s date, subscriber’s name, subscriber ID, and group number.
4. Indicate the state of residence for the patient and confirm whether services will be conducted in the same state by checking ‘Yes’ or ‘No’.
5. Complete the diagnostic practitioner information, including the practitioner’s name, NPI number, and type of practitioner.
6. Provide the primary and secondary diagnosis codes, along with the dates of evaluation for initial and follow-up assessments.
7. Enter the information for the ABA/team supervisor, including their name, license/certification number, and type of certification.
8. Certify the diagnosis and treatment expectation by choosing the appropriate checkbox and providing the necessary signatures.
9. Complete the provider information section, providing the facility name, NPI, address, and contact details.
10. Fill out the treatment request section, specifying the start date, requested service intensity, and total requested hours per week.
11. Document the ABA procedure codes and any additional codes or reasons for the request.
12. Provide a treatment history, detailing previous ABA services, including initial dates and intensity.
13. Complete the baseline and assessment information, selecting assessment instruments and entering scores.
14. List current maladaptive behaviors and their frequencies.
15. Outline the member’s treatment plan, including measurable goals and expected progress dates.
16. Document the parent involvement and the anticipated treatment fade/transition/discharge plan.
17. Once all sections are completed, save your changes. You can also download, print, or share the form as needed.

Complete your TX BCBS Form 749120.1118 online today to ensure timely processing of your request.