Physician's Order for Behavior Analysis Service Form

Child’s Name*
First Name Last Name
Date of Birth*
MM slash DD slash YYYY
Date*
MM slash DD slash YYYY
Medicaid ID#*
Mental Health Diagnosis*
This is a recommendation for behavior analysis services for*
This child presents with maladaptive behaviors that interfere with the child’s daily functioning and thus services are medically necessary to ensure safety and success at home and school.
Print Prescribing Physician Name*
Date
MM slash DD slash YYYY
Physician Signature (MUST BE MD)*
Doctor Office Name / Address
Physician License number
Phone Number

Referral Form Behavior Analysis Services
Date
MM slash DD slash YYYY
Referral Source name, number, email
Child’s Name
Child DOB
Child Gender
Child SS#
Child Home Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Child Resides with
Parent/Caregiver Name
Parent/Caregiver contact number
List other service providers, including name, agency and contact phone numbers
Child’s primary care physician
Child’s Diagnosis
Reason for referral
Behaviors of concern
Outcomes anticipated
Include copy of evaluation rendering diagnosis
Notes: In order to receive Behavior Analysis services from Behavior Basics through Medicaid Insurance all of the requested information is needed to get the service authorized. The physician (MD) must fill out the physician order completely and sign it. A copy of an evaluation on the referred child must be submitted as well to verify diagnosis and clinician rendering diagnosis.
CAPTCHA
Comments
This field is for validation purposes and should be left unchanged.

Referral Form Behavior Analysis Services