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All fields marked with * are required.

*Does your child have a diagnosis of autism?

Diagnosing Medical Profession Information:

*Name

*Address

*City

*State

*Zip code

*Please upload your diagnosis report.

Please click "choose file" to select a file. You may upload up to five files. After selecting the file, click the upload button to upload them. Click the X to delete a file.

*Do you allow us to contact the psychologist/physician?
Yes
No

In many cases insurance will not cover therapy without a diagnosis of autism. Feel free to continue filling out the application we can check with your insurance but in most cases this would mean services would be out of pocket.

*Has your child ever received a psychological exam?

Diagnosing Medical Profession Information:

*Name

*Address

*City

*State

*Zip code

*Please upload the psychological exam.

Please click "choose file" to select a file. You may upload up to five files. After selecting the file, click the upload button to upload them. Click the X to delete a file.

*Do you allow us to contact the psychologist/physician?
Yes
No

Page 3 of 3

All fields marked with * are required.

Primary Medical Insurance Company

Member ID or Policy Number

Group Number

Policy Holder Name

Policy Holder DOB

*Subscriber’s Social Security Number

Additional Information

If the policy belongs to another patient, specify the relationship here. Or, specify any other relevant information.

Second Insurance Company

Member ID or Policy Number

Group Number

Policy Holder DOB

Additional Information

If the policy belongs to another patient, specify the relationship here. Or, specify any other relevant information.

Please upload the front and back of your insurance card

Please click "choose file" to select a file. You may upload up to five files. After selecting the file, click the upload button to upload them. Click the X to delete a file.

Please upload your diagnosis report if you have one

Please click "choose file" to select a file. You may upload up to five files. After selecting the file, click the upload button to upload them. Click the X to delete a file.

Please upload your Diagnostic evaluation/report (completed by a doctorate level clinician,Diagnosis date and by whom)

Please click "choose file" to select a file. After selecting the file, click the upload button to upload them. Click the X to delete a file.

Please upload your MD prescription or signed coordination of care letter within the last 6 months

Please click "choose file" to select a file. After selecting the file, click the upload button to upload them. Click the X to delete a file.

[NOTE: Ordering physician information such as address, name, tax ID and phone number.]

Please upload any reports such as IEP, Speech, or ABA that you may have.

Please click "choose file" to select a file. You may upload up to five files. After selecting the file, click the upload button to upload them. Click the X to delete a file.

Age of the first ABA treatment

Do you have any secondary insurance including the Katie Beckett waiver, Deeming Waiver, and/or Medicaid?

*Please note per the GA Medicaid ASD manual: 801. Prior Approval for Adaptive Behavior Services (ABS) Prior Authorization (PA) is required for all Medicaid-covered ABS. Services without a PA will not be covered. A documented diagnosis of ASD must be established by a licensed physician or psychologist, or other licensed professional as designated by the Medical Composite Board prior to completing a PA for Behavioral Assessment or Treatment Services. As stated in 701, the diagnostic evaluation must use valid and reliable evaluation tools that conform to industry standards and include direct observation, parent/caregiver interviews, and standardized tools for the diagnosis of autism.

If so please include the following forms for a Medicaid authorization to be requested (with options to upload for the required ones place *)

1. Please upload your Diagnostic evaluation/report (Autism Diagnostic Observation Schedule – Second Edition (ADOS-2), Autism Diagnostic Interview – Revised (ADI-R), the Diagnostic Interview for Social and Communication Disorders (DISCO), and/or other known evidence-based tools. The diagnosis must be made by a practitioner enabled by the OCGA practice acts to diagnose behavioral health/ intellectual/developmental conditions. An initial diagnosis should include the following-nConducted within the past three (3) years. • Minimum of two (2) assessment tools (1 clinician observational assessment, 1 caregiver assessment). • Summary of each individual assessment. • Include the date it was completed and include the tests administered with scores. • Include the evaluators name and credentials. A diagnostic re-evaluation to re-confirm diagnosis is required, at a minimum, every three (3) years and must be completed by a licensed professional. The re-evaluation must include, at a minimum, 1 clinician observational assessment. Children who are three (3) years of age or younger when they receive an initial diagnostic assessment, should be re-evaluated in one (1) to two (2) years. School psychoeducational assessments are not acceptable for diagnostic evaluations.)

Please click "choose file" to select a file. After selecting the file, click the upload button to upload them. Click the X to delete a file.

2. Letter of Medical Necessity ( This can be completed by the diagnosis physician or child's pediatrician and must be dated within the last 6 months)

Please click "choose file" to select a file. After selecting the file, click the upload button to upload them. Click the X to delete a file.

3. Copy of the Medicaid card and/or Medicaid

Please click "choose file" to select a file. After selecting the file, click the upload button to upload them. Click the X to delete a file.

4. Individualized Family Service Plan (if applicable).

Please click "choose file" to select a file. After selecting the file, click the upload button to upload them. Click the X to delete a file.

5. Individual Education Plan or IEP

Please click "choose file" to select a file. After selecting the file, click the upload button to upload them. Click the X to delete a file.