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Applied Behavior Analysis (ABA)Clinical Service Request Form(Page 1 of 5)Check one: Initial Request Concurrent Request For any questions, call BCBSIL BCCHP at 877-860-2837 or BCBSIL MMAI at 877-723-7702 Fax Forms to 312-233-40991) For the Initial Treatment Request (ITR) Submit: Completed Clinical Service Request Form (pages 1-5), Diagnostic Evaluation Report, Provider Baseline and Skills AssessmentInstruments and Comprehensive Treatment Plan (additional information may be requested by a clinician once the case is reviewed)2)For the Concurrent Treatment Request (CCR) Submit: 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)PATIENT INFOPatient Name Patient Date of Birth Today’s DateSubscriber Name Subscriber ID Group Patient resides in what state? Services conducted in same state? Yes No If no, what state?DIAGNOSTIC PRACTITIONER INFODiagnostic Practitioner Name NPIDiagnostic Practitioner Type, if PCP: Family Practice Internal Medicine PediatricsDiagnostic Practitioner Type, if Specialized ASD-Diagnosing Provider: Developmental Behavioral Pediatrics Neurodevelopmental Pediatrics Child Neurology Adult or Child Psychiatry Licensed Clinical Psychology Other (specify)Primary Diagnosis Code Secondary Diagnosis Code Dates of Evaluations: Initial Follow UpBCBA, BCBA-D, PROFESSIONALLY LICENSED PRACTITIONER INFOABA/Team Supervisor Name License/Cert #Team Supervisor Certification and /or License (check what applies): Certified through the Behavior Analyst Certification Board (BACB): BCBA BCBA-D Professional Licensed Practitioners (minimum of six months specialized training): Licensed Clinical Psychology (PhD) Other LicensureMaster’s level clinician/state-recognized professional credential or certification StateCERTIFICATION OF DX & TREATMENT EXPECTATION I, Diagnostic Practitioner or ABA Services Supervisor (having confirmed with the diagnostician), am recommending ABA services and certifythere is a reasonable expectation that this member can actively participate and demonstrates the capacity to learn and develop generalized skills toassist in his/her independence and functional improvements.Line TherapistRequirementsABA SupervisorRequirementsRequirements for line staff providing 1:1 therapy: 1) 18 years of age; 2) High school diploma or GED; 3) criminalbackground check prior to active employment; 4) via practice expense, completed training of ASD & behavioralrelated subjects/evidence based techniques (40 hours) and 5) have on-going supervisory oversight by the BCBA orABA treatment supervisor for a minimum of 5% of hours directly worked with members.As the ABA Supervisor (above), I attest that I follow outlined guidelines for supervision by the BACB and have an Noactive license in the state where this member’s services are rendered. Yes CERTIFICATION OF PROVIDER QUALIFICATIONSBy signing and returning this form to Blue Cross and Blue Shield, I hereby certify: (1) credentials/license as noted above; (2) the line therapists forwhom 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 mustmeet the same qualifications; (4) time spent meeting the training requirements are not billable to BCBS or BCBS’s members and (5) BCBS may,in its discretion, review its claim history or request supporting information in order to verify the accuracy of this certification.ABA Supervisor Signature DateABA Supervisor Printed Name Clinic NameA Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association236239.1118

Applied Behavior Analysis (ABA)(Page 2 of 5)Patient Name Patient Date of BirthPROVIDER INFOFacility Name NPIAddress City State Zip CodeTelephone ext Fax Contact NameRendering BCBA Name License/Cert # NPIAddress (if not same as above) City State Zip CodeTelephone ext FaxPROVIDER TREATMENT REQUESTTreatment Request Start DateRequested Service Intensity: Focused ComprehensiveTotal Requested Hours Per Week (Note: Re-assessment package, for full clinical assessment, will be authorized every 6 months based on state plan)ABAProcedureCode Request97153DirectTreatment,Tech or QHPCodes97155ProtocolModification &Supervisionof ,QHP97156FamilyTreatment,QHP97157Multi FamilyTreatment,QHPUnits per 15minutesAdditional Code(s) Request and ReasonABA TREATMENT HISTORYInitial/First Date of ABA Services from current provider/facilityHas this member had ABA services with any other provider? No Yes When was the initial date?Intensity of these services: Focused Comprehensive Avg. # of hours/weekContinuous ABA services since start? Yes No If break from services, when and why? Sleep Issues Related to ASD? Yes No If yes, please describeMedical History Eating Issues Related to ASD? Yes No If yes, please describeIs the patient taking medication? Yes NoIf yes, prescribed by Professional Licensure/CredentialCurrent Medications (Dosages)A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association236239.1118

Applied Behavior Analysis (ABA)(Page 3 of 5)Patient Name Patient Date of BirthBASELINE & ASSESSMENT INFO02 162019Date Current Assessment Completed //Conducted by (name) License/CertAssessment Participants: Patient Only Parents/Caregivers Patient and Parents/CaregiversPlease select one (1) instrument that will be utilized for the member’s entire treatment episode so progress can effectively be measured. Choose arecognized instrument such as the VB MAPP, ABLLS, AFLS, ABAS or the Vineland. Also, please attach standardized measurement scoring summariesif the member has been in treatment prior to this request.Name of Assessment InstrumentCurrent Test DateCurrent Score/ /Name of Assessment InstrumentCurrent Test DatePrevious Test DatePrevious Test Score/ /Current Score/ /Previous Test ScorePrevious Test Score/ /CURRENT MALADAPTIVE BEHAVIORS(1) Behavior Freq per hour session day or week(2) Behavior Freq per hour session day or week(3) Behavior Freq per hour session day or week(4) Behavior Freq per hour session day or weekMEMBER TREATMENT PLANIntroDateBaseline(%)Measurable Member Treatment Goals(Goals from Different Domains)12345A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association236239.1118CurrentProgress/Data (%)ExpectedMastery Date

Applied Behavior Analysis (ABA)(Page 4 of 5)Patient Name Patient Date of BirthPARENT INVOLVEMENTThe parent/caregiver is expected to participate in training sessions hours per week.IntroDateBaseline(%)Measurable Member Treatment GoalsCurrentProgress/Data (%)123TREATMENT FADE/ TRANSITION/ DISCHARGE PLANMember’s Fade Plan: Member will step down from current hrs/week to hrs/week, on date / / orwithin months.Measurable Fade Plan with CriteriaDischarge PlanOther referrals/supports recommended at time of dischargeParent/Caregiver in agreement? Yes NoA Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association236239.1118ExpectedMastery Date

Applied Behavior Analysis (ABA)(Page 5 of 5)Patient Name Patient Date of BirthMember ABAScheduleDay of WeekTime SpanMember School andOther Therapy ScheduleLocationLunch / BreaksDay of WeekTime : to yTime : to :Time : to :Time SpanTime : to :MondayTime : to :Time : to :Time : to :Time : to :Time : to :Time : to :Time : to :Time : to :TuesdayTime : to :Time : to :Time : to :Time : to :Time : to :Time : to :Time : to :Time : to :WednesdayTime : to :Time : to :Time : to :Time : to :Time : to :Time : to :Time : to :Time : to :ThursdayTime : to :Time : to :Time : to :Time : to :Time : to :Time : to :Time : to :Time : to :FridayTime : to :Time : to :Time : to :Time : to :Time : to :Time : to :Time : to :Time : to :SaturdayTime : to :Time : to :Time : to :Time : to :Time : to :Time : to :Time : to :Time : to :SundayTime : to :Time : to :Time : to :Time : to : Member accessing other school program? Public Private Home Other (Specify)Member has IEP, ISP, 504 or ARD in place? Yes No If no, why not?Supports OutsideABA TreatmentIs this member accessing other therapeutic services? Physical Therapy Occupational Speech NAIs there coordination of care with other medical or BH providers? Yes No; Those areIs the family accessing community supports? Yes No Which onesMy signature confirms that I am providing/supervising the requested ABA services:ABA Supervisor Signature DateABA Supervisor Printed Name Clinic NameA Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association236239.1118

Other Licensure _ Master’s level clinician/state-recognized professional credential or certification . (40 hours) and 5) have on-going supervisory oversight by the BCBA or ABA treatment supervisor for a minimum of 5% of hours directly work