Client Registration FormLast Name First Name Middle Name Client SS# Client DOB MM slash DD slash YYYY Sex Male Female Address Street Address Apt# City State Zip Code Home# Cell#Email Diagnosis Diagnosis Code(s) Name of School Grade Referral Type Agency Parent/Guardian/Caregiver *Go to Parent/Guardian/Caregiver Information* Completed by Email Agency Name PhoneEmail *Parent/Guardian/Caregiver Information*Mother’s Last Name Mother’s First Name Mother’s SS# Mother’s DOB MM slash DD slash YYYY Mother’s Address Apt# City State Zip Code Home# Cell# Email Occupation Employer Father’s Last Name Father’s First Name Father’s SS# Father’s DOB MM slash DD slash YYYY Father’s Address Apt# City State Zip Code Cell# Home#Email Occupation Employer Service Type Requested Home-based ABA Therapy School-based ABA Therapy Community-based ABA Therapy DABA Group Homes (Coming Soon) DABA Centers (Coming Soon) Insurance Information Florida Medicaid StepUp for Students Medicaid Waiver Recipient/Client’s Insurance ID # Physician’s Order and CDE Requirements1. Upload Referral for ABA Therapy from Pediatrician/MD/Physician/Neurologist/Psychiatrist.Supported Files: .jpeg .pdf .docx Drop files here or Select files Max. file size: 100 MB, Max. files: 6. 2.Referral must be written on Prescription Pad on Letter Head OR written on a Referral / Script Sheet on Letter Head.3. Referral must have the following written on it or state the: a. Client’s Full Name, b. Client’s Date of Birth (DOB), c. ICD-10 Code Diagnosis, d. “ABA Therapy is Medically Necessary,” e. “Referral for ABA Assessment/Evaluation and Therapy” f. Referring Doctor’s Medicaid/Insurance Provider #, g. Referring Doctor’s NPI Number, and h. Signature of the Referring Doctor. Special NOTE: A CDE is a thorough review and assessment of the child’s development and behavior using national, evidence-based practice standards, which may include: • Parent or guardian interview /Teacher assessment • Diagnostic testing using tools such as: •Autism Diagnostic Observation Schedule (ADOS-2), •The Childhood Autism Rating Scale – 2nd edition (CARS2), •Modified Checklist for Autism in Toddlers, •Revised (M-CHAT-R), •Communication and Symbolic Behavior Scales (CSBS), •Autism Diagnostic Interview, Revised (ADI-R), •Social Communication Questionnaire, and/or •Battelle Developmental Inventory– 2nd edition. •Hearing, vision, Genetic testing, Neurological, and/or other medical testing4. Upload Comprehensive Diagnostic Evaluation (CDE) Report (Psychiatric, Neurological, and/or Psychological).Supported Files: .jpeg .pdf .docx Drop files here or Select files Max. file size: 100 MB, Max. files: 6. 5. NOTE: Attached CDE Report will be reviewed to determine if requirements set forth by insurance providers have been met in order to approve and provide ABA Therapy. CDE requirements will need to be met for continuation of ABA Therapy services. (772) 213-2301877-490-4507[email protected] www.dabasolutions.com
