Ongoing Care Request for ABA

Autism Program: 877-563-9347 Fax:816-237-2372

AuthorizationRequestforAppliedBehavioralAnalysisforAutismSpectrumDisorder

ThisformshouldbecompletedbytheBoardCertifiedBehaviorAnalyst (ABA) orapproved providerwho willberenderingand/orsupervisingtheservices.Pleasecompleteallpartsas clearlyandasspecificallyaspossible.Illegibilitymayresultina delayintheauthorization.

Omissionsandgeneralitiescouldresultinapeerreviewordenialduetolackofinformation.

This form should be completed, reviewed with parent(s) and submitted to New Directions

10 business days prior to the end of the current authorization for ongoing care requests.

IdentifyingData

Member’sName / Member’sID#
DateofBirth / Age
CurrentDiagnosisCode(s) / CurrentAuthorizationNumber

Parent/GuardianName(s) ContactNumber(s) Parent/GuardianEmailAddress

ProviderInformation

BCBA/ASName / ProviderNPI
GroupName / GroupTaxIDNumber
Address
Phone / Fax / Email
LineTherapistsInvolvedin Treatment
RequestedDateto BeginTreatment
BCBA/ASSignature / Date
Parent/GuardianhasreviewedandagreeswiththeTreatmentPlan
Parent/GuardianSignature / DateReviewedwithParent
*MD/PhDName / MD/PhDPhone
*MD/PhDhasreviewedandagreeswiththeTreatmentPlan
*MD/PhDSignature / DateReviewedwithMD/PhD

*Benefitsandrequirementsmayvarybyindividualstatemandatesfortheseservices.

NewDirectionsmayverifyparentorMD/PhDsignatureanddateoftreatmentplanreviewatanytime.

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TreatmentRequest

IndicatethetypeofTreatmentServicesbeing provided

☐Comprehensive ☐Focused

RationaleforServicesforrequestedauthorizationperiod:

MemberandParentSchedules

Write memberand/orparenttherapy/training timesin thefirstcolumn,CPTCodestobebilledin thesecond, and thesetting in thethird.Multiplecodesmaybelisted perline.

TotalHoursRequestedperWeek

Pleaseadd up thetreatmenthoursforeach CPTcodeand listtheminthedesignated spaces.

Member
ServiceCodes / 0359T* / 0360T0361T / 0364T0365T
*untimedsingle unit / 0366T& 0367T
0368T& 0369T(Treatmentby ProtocolModification) (ParentTraining)
FamilyGroupCodes / 0370T / 0371T / 0372T
ExposureCodes / 0362T& 0363T / 0373T / 0374T

MemberUpdate

PsychosocialInformationincludediagnostichistory,primarysupport/socialhistory,andfamily historyof ASDandrelateddisorders,historyof currentandpastbehavioralfunctioning,summaryof caregiverinterview

Educationincludegrade,currentandpreviousschoolsattended,datesandlocations,special educationorservicesprovided

Doesthememberhavean IEP? Ifyes,pleaseincludeacopy

CurrentMedicationsincludepsychotropic,over-the-counter,vitamins,andherbalremedies

MedicalHistoryincludemajorillnessorinjuries,hospitalizations,surgeries,diagnosesrelatedtoASD (FragileX,etc.)andallergies

Anyadditionalrelevantinformationincludesinformationsuchasidentifiedbarrierstoprogress, scheduling,orspecialcircumstances.

CurrentAssessments

VinelandAdaptiveBehaviorScaleScores DateCompleted
Composite / Communication / DailyLivingSkills / Socialization / MotorSkills
ComparedtopreviousAdaptiveBehaviorCompositeScore
☐ImprovedStandardDeviation / ☐SameStandardDeviation / ☐Dropin StandardDeviation
AssessmentName: / DateCompleted
InitialScore / PreviousScore / CurrentScore
☐NewAssessment / ☐SignificantChange / ☐Moderate / ☐MinimalChange / ☐NoChange
☐AssessmentWrite-Upand/orGraphIncluded
AssessmentName: / DateCompleted
InitialScore / PreviousScore / CurrentScore
☐NewAssessment / ☐SignificantChange / ☐Moderate / ☐MinimalChange / ☐NoChange
☐AssessmentWrite-Upand/orGraphIncluded
AssessmentName: / DateCompleted
InitialScore / PreviousScore / CurrentScore
☐NewAssessment / ☐SignificantChange / ☐Moderate / ☐MinimalChange / ☐NoChange
☐AssessmentWrite-Upand/orGraphIncluded

InstructionsforCompletingeachGoalSection

Pleaseprovideanupdateon thegoalsfromthelasttreatmentrequestand additionalgoalstobe completedin thenextsix-monthauthorization.

1. DateGoalBegan:Usethecalendarto selectthedatethegoalwasaddedtothetreatmentplan.

ThisshouldbethestartdateoftheORIGINALgoalevenifrevisionsto goalaremadeovertime.

2. GoalStatus:Usethedropdownmenuto selectthecurrentgoalstatus. Pleasebe sureto include goalsaddressedduringtheprevioussixmonthauthorizationandmarkasappropriate.

3. BaselineandPresentLevelofPerformance:Pleasedescribethespecificbehaviorsobservedfor

presentlevelofperformance.Ifgoaliscontinued,pleaseincludeinitialbaseline.Pleaseinclude correspondingdatesforinformation.

4 All goals should be written with measureable mastery criteria that can reasonably be achieved within six months. If longer term goals exist, include information in goal notes section. For each goal, include documentation of core symptoms of ASD identified on the treatment plan, date of goal introduction, estimated date of mastery, a specific plan for generalization of skills, and the number of hours per week estimated to achieve each goal.

5. GoalNotes:Additionalrelevantinformation.

a. Forcontinuedgoals,indicatechangesin goalorhowbarrier(s)are/havebeenaddressed. and percentage of progress toward mastery.

b. Fordiscontinuedgoals,indicatethereasonandterminationdate

c. Formasteredgoals,indicatedate mastered

Goals

Doesthememberhaveabehaviorplan?☐Yes☐No / Ifyes,pleaseattach.
Summaryof hoursspentbytypeof goal.
Pleaseincludeapproximatenumberof hoursandnumberofgoalsfromeacharea.
Adaptive:
#of goals:
Hoursperweek: / Behavior:
#of goals:
Hoursperweek: / Communication:
#of goals:
Hoursperweek: / SocialSkills:
#of goals:
Hoursperweek: / Other:
#of goals:
Hoursperweek:
DateGoalBegan / GoalStatus / DateGoalMastered
Number of hours per week estimated to achieve goal: ______
If goal was continued, indicate current percentage of progress towards completion:
Baselineand PresentLevelof PerformancewithCorrespondingDates
MeasurableGoalwithspecificmasterycriteria
GoalNotes

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DateGoalBegan / GoalStatus / DateGoalMastered
Number of hours per week estimated to achieve goal: ______
If goal was continued, indicate current percentage of progress towards completion:
BaselineandPresentLevelof PerformancewithCorrespondingDates
MeasurableGoalwithspecificmasterycriteria
GoalNotes
DateGoalBegan / GoalStatus / DateGoalMastered
Number of hours per week estimated to achieve goal: ______
If goal was continued, indicate current percentage of progress towards completion:
BaselineandPresentLevelof PerformancewithCorrespondingDates
MeasurableGoalwithspecificmasterycriteria
GoalNotes

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Parent/GuardianInvolvementandGoals

Summaryof participationandadditionalresourcesaccessedoverlastauthorizationperiod
ParentTrainingHoursScheduledweekly/monthly: / ☐Doesnot participate
ParentsGeneralizeSkillsinNatural Environment(Indicate%of goals familyisabletoimplement) / ☐80-100% / ☐51-79% / ☐21-50% / ☐Lessthan20%
Familyabletoimplement behaviorplanorinterventions(% of accuracyofimplementation) / ☐80-100% / ☐51-79% / ☐21-50% / ☐Lessthan20%
☐I attestthatparentparticipatedinatleast80%ofscheduledparenttraining.
☐I attestthatparenttrainingwasofferedandparentdidnotorrefusedtoparticipate.
ParentsDemonstrateUnderstandingoftheFollowingABAPrinciples
Principle / Mastered / Progressing / Targeted / NotYet
Addressed
Reinforcement / ☐ / ☐ / ☐ / ☐
DifferentialReinforcement / ☐ / ☐ / ☐ / ☐
MotivationalOperations / ☐ / ☐ / ☐ / ☐
Prompting / ☐ / ☐ / ☐ / ☐
Fading / ☐ / ☐ / ☐ / ☐
Shaping / ☐ / ☐ / ☐ / ☐
Antecedents / ☐ / ☐ / ☐ / ☐
Consequences / ☐ / ☐ / ☐ / ☐
DataCollection / ☐ / ☐ / ☐ / ☐
Collecting ABCData / ☐ / ☐ / ☐ / ☐
Identifying Functions / ☐ / ☐ / ☐ / ☐
Extinction / ☐ / ☐ / ☐ / ☐
TaskAnalysis / ☐ / ☐ / ☐ / ☐
Chaining / ☐ / ☐ / ☐ / ☐
Other: / ☐ / ☐ / ☐ / ☐
Other: / ☐ / ☐ / ☐ / ☐
Other: / ☐ / ☐ / ☐ / ☐
Other: / ☐ / ☐ / ☐ / ☐

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Pleasesummarizegoalsto betargetedduringtreatmentperiod.
Pleasesummarizeprogressongoalsfromthelastsixmonths.

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Coordination of Care

Pleasechecktheprovidersthatyouhavehadcoordinationof carewithduringthepastsixmonth authorization.Intheprovidedbox,pleasewritea summaryof theinformationrelevanttotreatment gatheredthroughcoordinationof carewitheachof theproviders.

☐ School / ☐ SpeechTherapist / ☐ PrimaryCarePhysician
☐ Psychologist
☐ Psychiatrist / ☐ OccupationalTherapist
☐ PhysicalTherapist / ☐ MentalHealth Therapist
☐ OtherRelevantProviders

Please entersummary ofrelevant information fromcoordination of care:

CommunityIntegrationandAftercarePlan

Pleasedescribethetransitionandaftercareplans.Pleaseincludetheinformationas outlined.AnticipatedOutcomeofTreatmentto includethefollowing:

descriptionoftheanticipatedoverallexpectationof member’sfunctionalperformanceasa resultoftreatment.

descriptionofthecoredeficitsofautismthatwillbetargetedforimprovement throughtreatmentto improvemember’soverallfunctioninglevel.

Transitionplanto includethefollowinginformation:

specificskillsto addresswithboththe familyandmemberandhowtheyareactively beingaddressedtopromotereadinesstomovetoa lowerlevelofcare

detailedstrategyfor movingtolowerlevelofcaredetailinghowhourswillbefaded connectedto measurableobjectivesforfamilyandmember

 communityresourcesidentifiedtosupportthefamily

communityresourcestosupportmember’sabilitytogeneralizeskillstovarious environmentsandprovidesupportasneeded

Aftercareplantoincludethefollowinginformation:

 Resourcesneededand/oridentified

 Reasonsforcontactafterdischarge

 Supportsinplacetoencouragesuccessfuldischarge

 Howserviceswouldresume,if needed

EstimatedEndDatetoMeetGoalOutcomesforTreatment:

 Completeforalltreatmentrequestsbeyondthefirstsixmonths

 NDunderstandsthattheestimatedenddatemaychangebasedonthemember’sprogressin

treatment

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OutcomeGoalsofTreatment

TransitionPlan

AftercarePlan

EstimatedEndDatetoMeetGoalOutcomesforTreatment:

☐I attestthattheNDABATreatmentRequestFormincludingprojectedtreatmentoutcomes, transitionplan,andaftercareplanwasdiscussedwithparent.

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