New Applied Behavior Analysis (ABA) Service Request Forms

March 31, 2021

As of March 2021, we’ve updated our ABA service request forms to streamline data required for review. To request services:

  • Download the appropriate new form from the Behavioral Health/Mental Health section on our Forms page. Please note for participants with the Employees Retirement System of Texas (ERS) or Teacher Retirement System of Texas (TRS), select the forms specific for ERS and TRS.

      The following forms have been updated.

    • Initial Assessment Request
    • Clinical Service Request for initial and concurrent treatment requests
  • Be sure to include the contact information and signature of the rendering Qualified Healthcare Provider (QHP) who is providing treatment.
  • Fax the completed form to 1-877-361-7646 at least two weeks before the requested start date. If we don’t receive the form within 30 days of the start date, you will need to submit claims through your normal process.

Questions? Call us at 1-800-528-7264.

Find other forms under Education and Reference.