Get Ma Tufts Health Plan Autism Applied Behavioral Analysis (aba) Concurrent Services Request Form 2011-2025

Completing the MA Tufts Health Plan Autism Applied Behavioral Analysis Concurrent Services Request Form is crucial for ensuring that members receive the necessary services. This guide will walk you through each section of the form, providing clear instructions to facilitate a smooth completion process.

Follow the steps to successfully complete the request form online.

1. Press the 'Get Form' button to access the ABA Concurrent Services Request Form and open it in your editing platform.
2. Begin by entering the date of the request at the top of the form. This date should reflect when the request is being submitted.
3. Fill in the member's details in the designated fields, including their full name, member ID, and date of birth. Ensure that all information is accurate to avoid any processing delays.
4. In the section for the treating professional, provide their name, discipline, provider ID number (if applicable), phone number, and complete mailing address. This information identifies who is making the request.
5. Select the services being requested from the options listed, such as applied behavior analysis and the corresponding codes. Also detail the total number of hours being requested for each service.
6. Indicate where the service will be provided by selecting the appropriate options (office or home) and specifying the required hours for daily, weekly, or monthly services.
7. List all diagnoses relevant to the member in the respective field, ensuring complete accuracy.
8. Construct a goal-orientated treatment plan. For each identified symptom or behavior, state a measurable goal, the progress made, and the expected timeframe to achieve the goal.
9. Explain the role of the parent or legal guardian in the treatment process and confirm their involvement in treatment sessions.
10. Detail any special services the member is receiving at school and/or in the community, noting that school-related services are not subject to reimbursement.
11. Finally, the requesting professional should sign and date the form. Ensure the form is submitted via fax or mail to the provided address after double-checking all entries for clarity and completeness.
12. Once completed, save changes to the document, and if needed, download, print, or share the form with relevant parties.

Begin filling out the MA Tufts Health Plan Autism Applied Behavioral Analysis Concurrent Services Request Form online today to ensure timely services.