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Non-waiver Medical Form

Welcome to Bauer ABA For Adults And Children And Early Intervention, where we prioritize transparency and communication with our clients. In our commitment to providing the highest quality Applied Behavior Analysis (ABA) services, we utilize a Non-Waiver ABA Form. This document is an essential part of our practice, ensuring that both families and our team are on the same page regarding the services provided.

Bauer ABA and Early Intervention » Non-Waiver Medical Form

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Download Non-waiver Medical Form

Non-waiver Medical Form

"*" indicates required fields

Member information

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Gender:
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Please enter a number from 1 to 100.

Provider information

Provider credential:
Is this an initial authorization request?
Is this an annual review?

DSM diagnosis:


Assessment and clinical documentation requirements:

All required clinical information is the responsibility of the referring and/or requesting provider to obtain and provide to Bauer ABA For Adults And Children And Early Intervention for a medical necessity determination.

1. Comprehensive Diagnostic Evaluation (CDE).

Treatment request:

ABA services



Behavioral Identification Assessment (ABA)


Behavioral Identification Supporting Assessment

Provider signature

My signature confirms that any paraprofessional under my supervision has the appropriate education, training, and certifications as applicable.


Max. file size: 64 MB.
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