3545 N.W. 58th St., Ste. 600, Oklahoma City, OK 73112
Phone: 405-717-8879 or 800-543-6044, ext. 8879
Fax: 1-405-949-5459 or 1-405-949-5501

APPLIED BEHAVIORAL ANALYSIS REQUEST

This form must be completed and accompany all requests. Incomplete forms will not be reviewed.


 
 
 
 
 
 
 

Submit written, signed and dated prescription from physician. Annual prescription is required.
 
 
 
 
 
 
 
 

Clinical assessment from diagnosing provider must be submitted for initial ABA request

 
 
 Center based
 School
 Home
 Other 
 


Submit assessment by ABA provider and ABA treatment plan (Required).


Submit current ABA treatment plan and documentation of progress in treatment (Required).
 



 



 



 



 
 

Services provided in the school are not covered by HealthChoice.
Services by Registered Behavioral Technician or Behavioral Tutor are not covered by HealthChoice.
 

** All information is required for review. Information provided is private and confidential. **

NOTE: These benefits are applicable only if the patient is an eligible enrolled member of a HealthChoice plan. All benefits are subject to the deductible, coinsurance and policy provisions. Please verify benefits and eligibility by calling the medical claims administrator toll-free at 800-323-4314.

MEDICARE PATIENTS: If HealthChoice provides coverage that is supplemental to Medicare, all requested services must be approved by Medicare. The Medicare EOB should be filed for claims processing.