Applied Behavioral Analysis Treatment Report Form - Horizon Blue Cross Blue Shield Of New Jersey
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1
2Applied Behavioral Analysis Treatment Report
Please indicate type(s) of service provided BY OTHERS (select all that apply):
Requested Start Date for this Authorization ______/______/______
Medication Management
Indiv. Psychotherapy
Family Psychotherapy
Group Therapy
Community Program(s)
Self Help Group(s)
Occupational Therapy
Physical Therapy
Speech Therapy
Patient Name: _______________________________________________________
__________________
___________________
__________________
Date of Birth: ___________________Age: ______________ Gender: _________
I am coordinating this patient’s case with other providers as appropriate.
Psychiatrist
Y N NA
Address (City/State only): _____________________________________________
Name: ________________________________________ Phone: ____________________________
Tel #: _____________________Patient’s Insurance ID#:_____________________
Psychotherapist:
Y N NA
Patient's Employer/Benefit Plan: ________________________________________
Name: ________________________________________ Phone: ____________________________
Primary Care Physician/Pediatrician:
Y N NA
Provider/Supervisor Name: ________________________________________
Name: ________________________________________ Phone: ____________________________
License _______________ Certification # (if applicable)____________________
Speech Therapist:
Y N NA
Name of Program/Clinic (if applicable): __________________________________
Name: ________________________________________ Phone: ____________________________
VO Provider ID # (if known): ________________Tel #______________________
Physical Therapist:
Y N NA
Service Address: ___________________________________________________
Name: ________________________________________ Phone: ____________________________
City/State/Zip: ______________________________________________________
Occupational Therapist:
Y N NA
Independently licensed provider in State where treating patient? Yes No
Name: ________________________________________ Phone: ____________________________
ABA Provider Certification BCBA BCBA-D State certification
Other Medical Provider:
Y N NA
Tax ID #: ________________________
NPI#: __________________________
Name: ________________________________________ Phone: ____________________________
Community Services Provider:
Y N NA
Additional Care Team Names (use additional sheets as necessary):
Name: ________________________________________ Phone: ____________________________
Paraprofessional/Technician: ____________________________________________
State/Regional Agency:
Y N NA
Attestation of qualifications by supervisor
Name: ________________________________________ Phone: ____________________________
Paraprofessional/Technician: ____________________________________________
School/Educational Provider:
Y N NA
Attestation of qualifications by supervisor
Name: _________________________________________ Phone: ____________________________
Paraprofessional/Technician: ____________________________________________
Attestation of qualifications by supervisor
IMPORTANT REMINDERS:
Diagnosis: ________________________________________________________
Qualified provider determining diagnosis (pediatrician, psychiatrist, MD, DO, in-
ABA Provider Report Guidelines are available at
dependently licensed and credentialed psychologist):
providers/Network/ABA/Report-Guidelines.pdf.
Name/Credential___________________________________________________
Please attach your treatment report to this form and ensure that all required
Tel # ______________________________
details as described in the ABA Provider Report guidelines are covered.
Treatment History: (please select all that apply in last 12 months)
Graphic representation of the progress made on each goal throughout the
Mental Health Substance Abuse Both None Unknown
whole review period must be included with the review.
Outpatient Partial/IOP Inpatient Residential Group Home
Other _______________________ Other _______________________
Current Medications including Psychotropic : Dosage and Frequency
Treating Provider’s Signature: _______________________________________Date: ___________
1. __________________________________________
___________________
Completed form can be faxed to: 855-241-8895 or mailed to:
2. __________________________________________
___________________
3. __________________________________________
___________________
Horizon Behavioral Health, Attn: ABA Team, PO Box 4274, Cherry Hill, NJ 08034
4. __________________________________________
___________________
5. __________________________________________
___________________
Page 1 of 2 The Horizon Behavioral Health program is administered by ValueOptions of New Jersey, Inc. .
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