Behavior Analysis Precertification Request

Patient Full Name

First NameLast Name

Patient Date of Birth

Date

Patient Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Patient Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Provider/Agency Name

Provider Contact Email

example@example.com

Referring Physician or Party (if applicable)

Insurance Provider Name

Summary of Behavioral Concerns

What are the primary assessment or treatment goals?

Have any previous behavioral interventions been attempted?

If yes, please describe previous interventions and outcomes.

Please rate the severity of current behavioral concerns.

Select the type(s) of behavior analysis service requested.

Additional Comments or Supporting Details (optional)

Signature of Requestor (Provider or Authorized Representative)