25-108 Access Applied Behavioral Analysis (ABA) Forms Online
Date: 02/07/25
Use the ABA forms to refer, and/or request ABA treatment for members and fulfill Plan requirements
You can find the ABA forms online in the Provider Library. Select the line of business; then on the left-hand column go to Forms and References. Refer to the table below on when to use the various ABA forms.
Form Name | Description |
|---|---|
Applied Behavioral Analysis (ABA) Recommendation and Referral Form (PDF) (Medi-Cal members) | This form is intended to fulfill the requirement set forth by the Department of Health Care Services (DHCS) that applied behavioral analysis (ABA) services require a medical necessity recommendation from a licensed physician or licensed psychologist. This form must be completed by a licensed physician or licensed psychologist. |
Applied Behavioral Analysis (ABA) Prior Authorization Request Form (PDF) (Medi-Cal and Commercial members) | All ABA services require prior authorization. ABA treating practitioners are required to submit a prior authorization request form along with an updated treatment plan to Health Net prior to delivering ABA services. |
Confirmation of Diagnosis: Autism Spectrum Diagnosis (ASD) form (PDF) (Commercial members) | This form is intended to fulfill the requirement set forth by commercial benefit plans that a licensed physician or licensed psychologist establish a diagnosis of autism and recommend ABA services. This form must be completed by a licensed physician or licensed psychologist. Attach a copy of the member’s most recent face-to-face evaluation and any additional supporting documentation (e.g., comprehensive diagnostic evaluation, prescription, physician letter, etc.) |
This information applies to Pediatricians and Behavioral Health Providers.
For Medi-Cal, this information applies to Amador, Calaveras, Inyo, Los Angeles, Molina, Mono, Sacramento, San Joaquin, Stanislaus, Tulare and Tuolumne counties.