Missing Piece Blog

What should be included in the ABA intake paperwork?

Initiating ABA services can be a cumbersome and time-consuming process for both the patient and the provider.  Documenting medical necessity and the need for services and the proper consents, are a critical part of a patient’s medical record.  Most of this information is gathered during the intake process, which starts before the patient’s first appointment. 

The essential components of the intake process are as follows:

  • Patient demographics
  • Patient funding information, including a copy of all insurance cards
  • Consent for services
  • Financial agreement or consent
  • HIPAA Policy Consent
  • Other Forms as deemed necessary by the organization
    • Attendance Contract
    • Letter of Engagement
    • Consent for Handbook or provider policies, if applicable
    • In Home therapy Survey, if applicable
    • Observation or Video Release form
    • Consent to release information to a third party, such as a physician, school, or another provider

Additionally, a provider may wish to obtain the following before the initial evaluation as these documents are typically required to obtain prior authorization:

  • Diagnostic report
  • Individualized Education Plan or IEP
  • Reports from other providers previously or currently in services
  • Referral or script from primary care or diagnosing physician

Each organization should create their intake and consent paperwork tailored to their needs, but they should refer to state and federal guidelines to meet requirements.  Some agencies prefer paper documentation that is mailed or emailed and printed, while many others are now utilizing online paperwork through the EMR systems or located on a website. 

Here are some additional components that may be beneficial to include:

  • Patient Demographics
  • History of Diagnosis- who diagnosed, where, when
  • Parent/Guardian(s) contact information
  • Primary Care Physician and contact information
  • Patient’s Medical History
    • Medication
    • History of Seizures
    • Surgeries or major medical history
    • Allergies
    • Other services currently receiving or previously received
      • Counseling or psychiatry
      • Speech, Occupational or physical therapy
      • Early Intervention services
      • Other relevant services
  • Patient’s Developmental History
  • Relevant Family Medical/Behavioral Health History
  • School/Educational History
  • Problem behaviors
  • Nutritional Background
  • Self-care Background
  • Verbal/Language Background
  • Social Skills Background
  • Family/Living Arrangements Background
    • Parent/Guardian Status
    • Siblings
  • Cultural or Religious Background
  • Parents Concerns or Goals for their child
  • Daily Routines/Schedules
  • Patient’s preferred items
    • Activities
    • Food
    • Items/Toys

Feeling lost on where to begin?  As part of the onboarding and implementation process, Missing Piece Billing and Consulting educates our providers on best practice guidelines for documentation through the revenue cycle process.  We also provide recommendation on how to incorporate this information into your individualized evaluation and treatment plan. 

To learn more, contact us today by email at weare@yourmissingpiece.com or by phone at 765-628-7400.