Behavior Therapy Reauthorization Form
Request continuation of behavior therapy services by providing the required non-sensitive details.
Patient Full Name
*
First Name
Last Name
Patient Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Provider/Agency Name
*
Provider Contact Email
*
example@example.com
Current Authorization Number or Reference
*
Current Service Setting
*
Please Select
Home
School
Clinic
Community
Other
Requested Continuation Start Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Requested Continuation End Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submitter Name and Role
*
Submit Reauthorization Request
Should be Empty: