Client Registration Form

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Sex
Address

Referral Type

*Parent/Guardian/Caregiver Information*

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Service Type Requested

Insurance Information

Physician’s Order and CDE Requirements

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    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 testing

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      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) 213-2301

      877-490-4507

      www.dabasolutions.com