Get the free DMAP 3117 ABA Enrollment Attachment for Applied Behavioral Analysis Organizations

DIVISION OF MEDICAL ASSISTANCE PROGRAMS Provider Enrollment Unit Provider Enrollment Attachment To be completed by Applied Behavioral Analysis Organizations only (Provider Name and Location for this

How to fill out dmap 3117 aba enrollment

How to Fill Out DMA 3117 ABA Enrollment:

1. Obtain the DMA 3117 ABA Enrollment form. This form is typically provided by the specific Medicaid agency responsible for administering the ABA (Applied Behavior Analysis) program.
2. Begin by carefully reading the instructions provided with the form. Make sure you understand the purpose of the form, the information required, and any specific guidelines or deadlines.
3. Fill out the top section of the form, which typically includes fields for personal information such as the participant's name, date of birth, address, and contact information. Ensure that all information is accurate and up-to-date.
4. Proceed to the next section, which typically requires details about the primary caregiver or responsible party. This may include their name, relationship to the participant, contact information, and any additional relevant details.
5. Move on to the section that pertains to the ABA provider or agency. Here, you will typically need to provide the provider's name, address, contact information, and Medicaid provider identification number, if applicable.
6. Complete the following sections, which usually require information related to the participant's Medicaid eligibility, diagnosis, and any other necessary details specified by the form. This may include providing copies of supporting documents, such as the participant's Medicaid card or diagnosis documentation from a healthcare professional.
7. Pay close attention to any signature lines or consent sections that may be included in the form. Ensure that all necessary parties have signed and dated the form appropriately.
8. Verify that you have included any additional supporting documentation or attachments required by the specific Medicaid agency or program.
9. Once you have filled out the entire form and attached any necessary documentation, review it carefully to ensure accuracy and completeness. Make any necessary corrections or additions before submitting it.
10. Finally, submit the completed DMA 3117 ABA Enrollment form to the appropriate Medicaid agency or ABA program administrator. Follow any specific instructions provided for submission, such as mailing, faxing, or electronically uploading the form.

Who Needs DMA 3117 ABA Enrollment?

1. Individuals with Medicaid coverage who require or desire ABA services for themselves or their dependent. ABA is often used as an evidence-based therapy for individuals with autism spectrum disorder (ASD) but may also be applicable for individuals with other developmental disabilities or behavioral challenges.
2. Parents or legal guardians who are seeking ABA services for their child or dependent with Medicaid coverage.
3. ABA providers or agencies who are enrolling participants in the Medicaid ABA program and are required to complete the DMA 3117 ABA Enrollment form on behalf of their clients.

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What is dmap 3117 aba enrollment?

Dmap 3117 aba enrollment is a form used for enrolling in the Applied Behavior Analysis (ABA) program under the Developmental Disabilities Administration (DDA).

Who is required to file dmap 3117 aba enrollment?

Individuals with developmental disabilities who are seeking or currently receiving ABA services are required to file dmap 3117 aba enrollment.

How to fill out dmap 3117 aba enrollment?

Dmap 3117 aba enrollment can be filled out online through the DDA portal or by contacting the DDA directly for assistance.

What is the purpose of dmap 3117 aba enrollment?

The purpose of dmap 3117 aba enrollment is to officially enroll individuals in the ABA program and ensure they receive the necessary services and support.

What information must be reported on dmap 3117 aba enrollment?

Information such as personal details, medical history, diagnosis, treatment goals, and guardian information must be reported on dmap 3117 aba enrollment.