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Captures patient, subscriber, diagnostic practitioner, and rendering provider information, required diagnostic timeliness, and provider certification of qualifications. Documents treatment request start date, service intensity, ABA procedure code selections with units per 15 minutes, treatment history, and certification of diagnostic and treatment expectations, including requirements for line therapists and ABA supervisors.",{"@graph":14,"@context":72},[15,34,55],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/applied-behavior-analysis-clinical-service-request-form/287754/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/applied-behavior-analysis-clinical-service-request-form/287754.png","ImageObject",442,249,{"name":42,"@type":43},"Mimi","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-09-24","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":30},"InteractionCounter",{"@type":54},"ViewAction",{"@type":56,"mainEntity":57},"FAQPage",[58,64,68],{"name":59,"@type":60,"acceptedAnswer":61},"What is the minimum lead time to submit this ABA clinical service request form?","Question",{"text":62,"@type":63},"Submit the forms at least two weeks before the requested start date.","Answer",{"name":65,"@type":60,"acceptedAnswer":66},"What supporting documents are required for an initial ABA treatment request?",{"text":67,"@type":63},"Submit the completed Clinical Service Request Form (pages 1–5), a Diagnostic Evaluation Report, and provider baseline and skills assessment instruments plus a comprehensive treatment plan.",{"name":69,"@type":60,"acceptedAnswer":70},"Which ABA procedure code information must be provided in the provider treatment request section?",{"text":71,"@type":63},"Select the requested ABA procedure code(s) and provide the required units per 15 minutes, along with any additional codes and the reason for the request.","https://schema.org",{"og:url":32,"og:type":74,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":76,"canonical":32},"index,follow",{"doc_id":78,"site_id":7},287754,1790204824,{"code":4,"msg":81,"data":82},"success",[83,88,93,98,103,108,112,117,122],{"id":84,"doc_module":22,"doc_module_name":25,"category_name":85,"show_sort_weight":86,"slug":87},11,"Presentations",90,"presentations",{"id":89,"doc_module":22,"doc_module_name":25,"category_name":90,"show_sort_weight":91,"slug":92},12,"Resumes",80,"resumes",{"id":94,"doc_module":22,"doc_module_name":25,"category_name":95,"show_sort_weight":96,"slug":97},14,"Invoices",70,"invoices",{"id":99,"doc_module":22,"doc_module_name":25,"category_name":100,"show_sort_weight":101,"slug":102},15,"Posters",60,"posters",{"id":104,"doc_module":22,"doc_module_name":25,"category_name":105,"show_sort_weight":106,"slug":107},16,"Social Media",50,"social-media",{"id":109,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":110,"slug":111},17,40,"forms",{"id":113,"doc_module":22,"doc_module_name":25,"category_name":114,"show_sort_weight":115,"slug":116},18,"Letters",30,"letters",{"id":118,"doc_module":22,"doc_module_name":25,"category_name":119,"show_sort_weight":120,"slug":121},21,"Paper Templates",5,"papers-templates",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":4,"slug":125},158,"General","general-158",{"code":4,"msg":81,"data":127},{"doc_id":78,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":109,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":30,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":120,"language":135,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":12,"update_tm":139,"read_time":26},2336477974920,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","Applied Behavior Analysis  \nClinical Service Request Form  \n(Page 1 of 5)  \n Check one:  Initial Request  Concurrent Request   \nSubmit forms at least two weeks before requested start date.  \nFor any questions, call Blue Cross and Blue Shield of Texas at 800-851-7498 or BCBSTX Federal Employee Program® at 800-779-4602. Fax forms to 877-361-7646.  \n1) For the Initial Treatment Request  \nSubmit: Completed Clinical Service Request Form (pages 1-5), Diagnostic Evaluation Report, Provider Baseline and Skills Assessment Instruments and Comprehensive Treatment Plan (additional information may be requested by a clinician once the case is reviewed)  \n2) For the Concurrent Treatment Request  \nSubmit: Completed Clinical Service Request Form (pages 1-5), Skills Re-Assessment Report and Comprehensive Treatment Plan (additional information may be requested by a clinician once the case is reviewed)  \nPATIENT INFO  \nPatient Name   Patient Date of Birth   Today’s Date   Subscriber Name   Subscriber ID   Group   Patient resides in what state?    \nDIAGNOSTIC PRACTITIONER INFO  \nDiagnostic Practitioner Name   NPI   Diagnostic Practitioner Type, if PCP: 􀁆 Family Practice 􀁆 Internal Medicine 􀁆 Pediatrics  \nDiagnostic Practitioner Type, if Specialized ASD-Diagnosing Provider: 􀁆 Developmental Behavioral Pediatrics 􀁆 Neurodevelopmental Pediatrics  \n􀁆 Child Neurology 􀁆 Adult or Child Psychiatry 􀁆 Licensed Clinical Psychology 􀁆 Other (specify)    \nPrimary Diagnosis Code   Secondary Diagnosis Code   Current diagnostic required not older than 36 months.  \nInitial Evaluation Date   Most Recent Evaluation Date    \nPROVIDER INFO  \nRendering Qualified Healthcare Provider (QHP)* Name  *Fill in the Rendering QHP who is directly providing treatment.  \nNPI   Email   Telephone (please provide a number with confidential voicemail)   ext   Master’s/PhD level clinician/state-recognized professional credential or certification   State   License/Cert\\#    \nClinic Practice Name   NPI   Fax    \nClinic Practice Rendering  \nProvider Address   City   State   Zip Code   Practice Contact Name   Telephone   ext   Admin Billing Office Address    \nCERTIFICATION OF DX & TREATMENT EXPECTATION  \nI, 􀁆 Diagnostic Practitioner or 􀁆 ABA Services Supervisor (having confirmed with the diagnostician), am recommending ABA services and certify there is a reasonable expectation that this member can actively participate and demonstrates the capacity to learn and develop generalized skills to assist in his/her independence and functional improvements.  \n\n| Line Therapist Requirements | Requirements for line staff providing 1:1 therapy: 1) 18+ years of age; 2) High school diploma or GED; 3) criminal background check prior to active employment; 4) via practice expense, completed training of ASD and behavioral related subjects/evidence based techniques (40 hours) and 5) have on-going supervisory oversight by the BCBA or ABA treatment supervisor for a minimum of 5% of hours directly worked with members. |\n| --- | --- |\n| ABA Supervisor Requirements | As the ABA Supervisor (above), I attest that I follow outlined guidelines for supervision by the BACB and have an active license in the state where this member’s services are rendered. 􀁆 Yes 􀁆 No |\n\nBlue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation,  \na Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association 764438.1125  \nApplied Behavior Analysis  \n(Page 2 of 5)  \nPatient Name   Patient Date of Birth    \nCERTIFICATION OF PROVIDER QUALIFICATIONS  \nBy signing and returning this form to Blue Cross and Blue Shield of Texas, I hereby certify: (1) credentials/license as noted above; (2) the line therapists for whom I, or an outpatient mental health agency or clinic, will bill meet the qualifications set forth above; (3) if staff changes at any time, new staff must meet the same qualifications; (4) time spent meeting the training requirements are not billable to BCBSTX or members of","cbCaifIuy8rhQKUr","https://ap.wps.com/l/cbCaifIuy8rhQKUr","pdf",402280,"English","# Clinical Service Request Overview\n## Submission timing and required documents\n## Patient and subscriber information\n## Diagnostic practitioner information\n## Provider information\n## Certification of diagnosis and treatment expectation\n## Line therapist and ABA supervisor requirements\n## Certification of provider qualifications\n## Provider treatment request and ABA procedure codes\n## Treatment history","[{\"question\":\"What is the minimum lead time to submit this ABA clinical service request form?\",\"answer\":\"Submit the forms at least two weeks before the requested start date.\"},{\"question\":\"What supporting documents are required for an initial ABA treatment request?\",\"answer\":\"Submit the completed Clinical Service Request Form (pages 1–5), a Diagnostic Evaluation Report, and provider baseline and skills assessment instruments plus a comprehensive treatment plan.\"},{\"question\":\"Which ABA procedure code information must be provided in the provider treatment request section?\",\"answer\":\"Select the requested ABA procedure code(s) and provide the required units per 15 minutes, along with any additional codes and the reason for the request.\"}]","Applied Behavior Analysis - Clinical Service Request Form | PDF",1789632695]