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Collects patient demographics, insurance and employer/benefit plan identifiers, provider credentials (e.g., BCBA and NPI), service address, and requested authorization start date. Requires selection of request type, requested program setting and hours, submission of a complete treatment plan, and detailed service codes with unit and clinical-justification fields. Units are defined in 15-minute increments and support assessment, direct 1:1 therapy, group treatment, and family training.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/aba-authorization-request-form/288901/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/aba-authorization-request-form/288901.png","ImageObject",442,249,{"name":88,"@type":89},"Rowan","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-12","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":15},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What types of requests can be submitted with this form?","Question",{"text":108,"@type":109},"Use the form for initial and concurrent requests, and indicate whether it is an initial assessment, initial treatment, or a concurrent request.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How are units and time tracked for the requested ABA services?",{"text":113,"@type":109},"All units are 15 minutes; 4 units equal 1 hour. The form also asks for hours per week or hours per day and days per week depending on the selected service.",{"name":115,"@type":106,"acceptedAnswer":116},"What documentation is required to accompany the request?",{"text":117,"@type":109},"A complete treatment plan must be submitted with the authorization request.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},288901,1789968685,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":15,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":9},1099514067415,"https://ap-avatar.wpscdn.com/avatar/100002539d78ffe74a7?x-image-process=image/resize,m_fixed,w_180,h_180&k=1779092875211072502","CARELON BEHAVIORAL HEALTH  \nABA AUTHORIZATION REQUEST  \nUse this form for both initial and concurrent requests. Please indicate the type of request, as well as the type of services requested. Include the number of requested units as well as hours per day, and hours or days per week, as indicated. Please submit a complete treatment plan with this request.  \nRequested Start Date for this Authorization:    \nRequest for:  \n􀂉 Initial Assessment 􀂉 Initial Treatment 􀂉 Concurrent Request  \nPatient’s Name:    \nDate of Birth:   Age:   􀂉 M 􀂉 F 􀂉 Other:    \nPhone Number:   Patient’s Insurance ID\\#:    \nPatient's Employer/Benefit Plan:    \nProvider/Supervisor (BCBA, LBA, LABA, other)  \nName:   ABA Provider Type: 􀂉 BCBA 􀂉 State Licensed/Certified  \nCertification/License \\#:   State:    \nNPI \\#:   Provider ID (if known)  \nPhone Number:    \nEmail address:    \nProvider Group/Agency:    \nTIN \\#:   Provider Group ID \\# (if known):    \nService Address:    \nCity/State/Zip:    \nPhone Number:    \nEmail address:    \nSERVICES REQUESTED  \n(All units are 15 minutes; 4 units equal 1 hour)  \nProgram setting and hours per week:  \n􀂉 Home   􀂉 Facility/Clinic   􀂉 School   􀂉 Other:    \nAssessment / Follow-up Assessment  \nBy physician or other qualified health care professional (QHP) . Behavior identification assessment, administration of tests, detailed behavioral history, observation, caretaker interview, interpretation, discussion of findings, recommendations, preparation of report, development of treatment plan. Assessment of strengths and weaknesses of skill areas across skill domains (e.g. , VB-MAPP, ABLLS-R, Functional Behavior Assessment, Functional Analysis) and follow-up assessments.  \n􀂉 97151: Behavior identification assessment (initial or reassessment) administered by a physician/QHP. Units are in 15-minute increments; up to 32 units max for initial, up to 32 units max for reassessment  \nwith clinical justification. Units Requested:    \n􀂉 97152: Behavior identification supporting assessment administered by technician under direction of physician/ QHP, face to face with patient. Units are in 15-minute increments. Clinical justification required.  \nUnits Requested:    \n􀂉 0362T: Behavior identification supporting assessment for severe behaviors administered by a physician/QHP who is on-site, with the assistance of two or more technicians, for a patient who exhibits destructive behavior, completed in an environment that is customized to a patient's behavior. Units are in 15-minute increments. Clinical justification required.  \nUnits Requested:    \nDirect 1:1 ABA Therapy  \n􀂉 97153: Adaptive behavior treatment by protocol administered by technician under the direction of physician/ QHP, receiving 1 hour of supervision for every 5 to 10 hours of direct treatment. Units are in 15-minute increments.  \nHours per week:   Units Requested:    \n􀂉 97155: Adaptive behavior treatment with protocol modification, administered by physician/QHP. May be used for Direction of Technician (Supervision) face-to-face with one patient. Units are in 15-minute increments. Hours per day:   Days per week:   Units Requested:    \n􀂉 0373T: Adaptive behavior treatment with protocol modification implemented by physician/QHP who is on-site with the assistance of two or more technicians for severe maladaptive behaviors. Units are in 15-minute increments. Clinical justification required.  \nHours per week:   Units Requested:    \nGroup Adaptive Behavior Treatment  \n􀂉 97154: Group adaptive behavior treatment by protocol by technician under the direction of physician/QHP, face  \n-to-face with two or more patients. Units are in 15-minute increments.  \nHours per day:   Days per week:   Units Requested:    \n􀂉 97158: Group adaptive behavior treatment with protocol modification (Social Skills Group) by physician/QHP, face-to-face with two or more patients. Units are in 15-minute increments.  \nHours per day:   Days per week:   Units Requested:    \nFamily Adaptive Behavior Treatment Guidance (Family","cbCaiucDFiFsDM2n","https://ap.wps.com/l/cbCaiucDFiFsDM2n","pdf",308832,"English","# Requested Start Date for this Authorization\n# Patient Information\n# Provider/Supervisor Information\n# Services Requested\n## Request for Type and Program Setting\n## Assessment / Follow-up Assessment\n## Direct 1:1 ABA Therapy\n## Group Adaptive Behavior Treatment\n## Family Training (Family Adaptive Behavior Guidance)","[{\"question\":\"What types of requests can be submitted with this form?\",\"answer\":\"Use the form for initial and concurrent requests, and indicate whether it is an initial assessment, initial treatment, or a concurrent request.\"},{\"question\":\"How are units and time tracked for the requested ABA services?\",\"answer\":\"All units are 15 minutes; 4 units equal 1 hour. The form also asks for hours per week or hours per day and days per week depending on the selected service.\"},{\"question\":\"What documentation is required to accompany the request?\",\"answer\":\"A complete treatment plan must be submitted with the authorization request.\"}]","ABA Authorization Request Form | PDF",1789634184]