Follow the steps to complete the registration/authorization form

1. Press the ‘Get Form’ button to obtain the CT BHP ASD Registration/Authorization Template and open it in your preferred online editor.
2. Begin by entering the facility or provider name at the top of the form to specify who is providing the service.
3. Fill in the name of the contact person who is completing the form to ensure communication can be established.
4. Provide the contact number and extension for the individual just mentioned to facilitate easy follow-up.
5. Enter the member's name and their Medicaid or consumer ID number. This identifies the individual receiving services.
6. Input the date of birth (DOB) of the member to further verify their identity.
7. Document the ABA service required, selecting the appropriate CPT code from the options provided in the template.
8. Specify the maximum units or hours allowed for each service, referencing the treatment plan.
9. Indicate the requested start date for services to ensure timely provision.
10. Detail the requested hours per week for the services, adhering to the outlined maximums.
11. Select the location of services, indicating where the ABA therapy will take place — whether at home, in an office, or within the community.
12. Identify who will be providing the service, marking whether it is a BCBA, LCSW, APRN, technician, or another qualified provider.
13. Review all entries for accuracy and completeness. Once confirmed, you can save changes, download, print, or share the completed form as needed.

Start completing your CT BHP ASD Registration/Authorization Template online today!