Get Ct Bhp Asd Registration/authorization Template 2020-2026

This guide provides comprehensive instructions for users on how to complete the CT BHP ASD Registration/Authorization Template online. Whether you are a health care provider or a caretaker, this step-by-step approach will ensure that your form is completed accurately and efficiently.

Follow the steps to fill out the form correctly.

1. Press the ‘Get Form’ button to access the CT BHP ASD Registration/Authorization Template and open it in the editor.
2. In the first section, enter the facility or provider name along with the name of the individual who completed the form. Provide an accurate contact number and extension.
3. Next, fill in the member's name and their Medicaid or Consumer ID number. This is crucial for identification and processing.
4. Specify the ABA service that is being requested along with the relevant CPT code. Ensure you provide the date of birth and, if necessary, the Social Security Number.
5. Indicate the requested start date for the services and outline the number of units or hours per week that are needed.
6. Choose the location where services will be provided, such as home, office, or community settings.
7. Include the name and title of the individual providing the service, such as a BCBA, licensed clinician, or technician.
8. For the ABA assessment request, state the code H0031 and provide a clinical rationale detailing the anticipated tools and methods that will be employed.
9. Complete the ABA services request section by specifying the required therapies, including hours per week for each type of service requested.
10. Review all entered information for accuracy and completeness. Once verified, you can save changes, download, print, or share the form as needed.

Start filling out your documents online today to ensure a smooth registration process.