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Get the free HMSA ABA Application Addendum - 9/28/17

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Behavioral Health Facility/Program Application Addendum For HMS As ABA Qualified Provider Network This addendum must be completed for all providers who will render care within your organizations ABA
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How to fill out hmsa aba application addendum

01
To fill out the HMSA ABA Application Addendum, follow these steps:
02
Start by providing your personal contact information like your name, address, phone number, and email address.
03
Indicate the name and address of the provider for whom the addendum is being completed.
04
Specify the requested ABA service start and end dates.
05
If you have an existing ABA provider, indicate their information and whether they are being replaced or continue to be maintained concurrent with this application.
06
Outline any additional ABA providers currently active or requested to be active.
07
Provide detailed information about the diagnosis, including the date of diagnosis, assessment tool used, and the name of the qualified professional who made the diagnosis.
08
Complete the Insurance Verification section by including the primary insurer's name, policyholder information, and coverage details.
09
Sign and date the addendum to acknowledge the accuracy of the information provided.
10
Submit the completed addendum along with the main application form.

Who needs hmsa aba application addendum?

01
The HMSA ABA Application Addendum is needed by individuals who require Applied Behavior Analysis (ABA) services for themselves or their dependents. This addendum is often used in conjunction with the main HMSA ABA application form and helps to provide more specific information about the individual's diagnosis, ABA providers, and insurance coverage.
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The HMSA ABA application addendum is a supplementary form that is required to be completed in addition to the standard application for ABA services.
Providers and practitioners who wish to offer ABA services through HMSA are required to file the application addendum.
The HMSA ABA application addendum can be filled out online or submitted via mail with all required information and documentation.
The purpose of the HMSA ABA application addendum is to gather specific information related to the provider or practitioner offering ABA services.
The application addendum requires information such as provider credentials, ABA training, treatment protocols, and any relevant certifications or licensing.
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