This is the information that we need written in an ABA referral on referring provider letterhead (not Tricare):
- Name of Patient
- Date of Order
- Patient Diagnosis of Autism Spectrum Disorder
- DOB of Patient
- Insurance Provider
- Contact Phone Number
- "This is a referral for A New Leaf Therapeutic Services PLLC to provide Applied Behavior Analysis"
- Signature of treating/overseeing provider
- Printed name of treating/overseeing provider
- NPI # of referring provider
Are you a doctor or family looking for a referral form?