Info Needed Report-ABA

"*" indicates required fields

Your Name*
Hidden
Hidden
MM slash DD slash YYYY
Please complete the ABA Insurance Verification Request Form for this patient so that we can get patient’s demographics, diagnosis, and/or insurance card needed for billing.
Please upload the patient’s prescription form in Teamwork Chat.
Please let us know in Teamwork Chat which modifier that this patient with Medicaid will utilize. TG or TF
On the following billing form submitted, we need additional clarification. Please let us know in Teamwork Chat the answer to our question(s).
The following Medicaid Prior Authorizations are set to expire soon. Here is the patient name and date that the current prior auth will expire with Medicaid.
This field is for validation purposes and should be left unchanged.