ABA Weekly Billing Clinic Name* Patient First Name* Patient Last Name* HiddenPhone*Do not edit. Pre-filled for your convenience.HiddenEmail*Do not edit. Pre-filled for your convenience. Type of Insurance* Commercial Medicaid Commercial + Medicaid Tricare East - Humana Military Commercial - Allows Concurrent Billing (Optum-UHC, UMR, others) Supervising BCBA for this patient?Choose OneKirsten MasrelianCarissa VanAstenChristy JahnsEmily BaumlerHannah MaroseKaylea QuinnSupervising BCBA for this patient.Angela WadeKim Nichols-GreenSupervising BCBA for this patient.Sara BrunclikDate of Care* MM slash DD slash YYYY Care Received*Please select ALL the codes this patient received on this date. 97151-Assessment 97152-Follow-up Assessment 97153-ABT 97155-ABT with Protocol Modification-Supervision 97155-ABT with Protocol Modification-Solo 97156-Family ABT Guidance 97156 AM - Team Meeting 97154 - Group ABT by Protocol 97158 - Group ABT with Protocol Modification-Social Skills Group 0373T - ABT with Protocol Modification - 2 Technicians 97151 - Units Received1 Unit = 15 minutesWho Performed 97151?Please list first and last name of provider AND the number of units each provider performed.Who Performed 97152?Please list first and last name of provider AND the number of units each provider performed.97152 - Units Received1 Unit = 15 minutesWho Performed 97153?Please list first and last name of provider.97153 - Units Received1 Unit = 15 minutes97153 - Adjusted Units to BillWho Performed 97155 Supervision?Please list first and last name of provider.97155 Supervision - Units Received1 Unit = 15 minutesWho Performed 97155 Solo?Please list first and last name of provider AND the number of units each provider performed.97155 Solo - Units Received1 Unit = 15 minutesWho Performed 97156 Family ABT Guidance?Please list first and last name of provider AND the number of units each provider performed.97156 Family ABT Guidance - Units Received1 Unit = 15 minutesWho Performed 97156 AM Team Meeting?Please list first and last name of provider AND the number of units each provider performed.97156 AM Team Meeting - Units Received1 Unit = 15 minutesWho Performed 97154?Please list first and last name of provider AND the number of units each provider performed.97154 - Units Received1 Unit = 15 minutesWho Performed 97158?Please list first and last name of provider AND the number of units each provider performed.97158 - Units Received1 Unit = 15 minutesWho Performed 0373T?Please list first and last name of provider AND the number of units each provider performed.0373T - Units Received1 Unit = 15 minutesIs there another date of service for this patient? Yes No Date of Care* MM slash DD slash YYYY Care ReceivedPlease select ALL the codes this patient received on this date. 97151-Assessment 97152-Follow-up Assessment 97153-ABT 97155-ABT with Protocol Modification-Supervision 97155-ABT with Protocol Modification-Solo 97156-Family ABT Guidance 97156 AM - Team Meeting 97154 - Group ABT by Protocol 97158 - Group ABT with Protocol Modification-Social Skills Group 0373T - ABT with Protocol Modification - 2 Technicians Who Performed 97151?Please list first and last name of provider AND the number of units each provider performed.97151 - Units Received1 Unit = 15 minutesWho Performed 97152?Please list first and last name of provider AND the number of units each provider performed.97152 - Units Received1 Unit = 15 minutesWho Performed 97153?Please list first and last name of provider.97153 - Units Received1 Unit = 15 minutes97153 - Adjusted Units to BillWho Performed 97155 Supervison?Please list first and last name of provider.97155 Supervision - Units Received1 Unit = 15 minutesWho Performed 97155 Solo?Please list first and last name of provider AND the number of units each provider performed.97155 Solo - Units Received1 Unit = 15 minutesWho Performed 97156 Family ABT Guidance?Please list first and last name of provider AND the number of units each provider performed.97156 Family ABT Guidance - Units Received1 Unit = 15 minutesWho Performed 97156 AM Team Meeting?Please list first and last name of provider AND the number of units each provider performed.97156 AM - Team Meeting - Units Received1 Unit = 15 minutesWho Performed 97154?Please list first and last name of provider AND the number of units each provider performed.97154 - Group ABT by Protocol1 Unit = 15 minutesWho Performed 97158?Please list first and last name of provider AND the number of units each provider performed.97158 - Group ABT with Protocol Modification-Social Skills Group1 Unit = 15 minutesWho Performed 0373T?Please list first and last name of provider AND the number of units each provider performed.0373T - Units Received1 Unit = 15 minutesIs there another date of service for this patient? Yes No Date of Care* MM slash DD slash YYYY Care ReceivedPlease select ALL the codes this patient received on this date. 97151-Assessment 97152-Follow-up Assessment 97153-ABT 97155-ABT with Protocol Modification-Supervision 97155-ABT with Protocol Modification-Solo 97156-Family ABT Guidance 97156 AM - Team Meeting 97154 - Group ABT by Protocol 97158 - Group ABT with Protocol Modification-Social Skills Group 0373T - ABT with Protocol Modification - 2 Technicians Who Performed 97151?Please list first and last name of provider AND the number of units each provider performed.97151 - Units Received1 Unit = 15 minutesWho Performed 97152?Please list first and last name of provider AND the number of units each provider performed.97152 - Units Received1 Unit = 15 minutesWho Performed 97153?Please list first and last name of provider.97153 - Units Received1 Unit = 15 minutes97153 - Adjusted Units to BillWho Performed 97155 Supervision?Please list first and last name of provider.97155 Supervision - Units Received1 Unit = 15 minutesWho Performed 97155 Solo?Please list first and last name of provider AND the number of units each provider performed.97155 Solo - Units Received1 Unit = 15 minutesWho Performed 97156 Family ABT Guidance?Please list first and last name of provider AND the number of units each provider performed.97156 Family ABT Guidance - Units Received1 Unit = 15 minutesWho Performed 97156 AM - Team Meeting?Please list first and last name of provider AND the number of units each provider performed.97156 AM - Team Meeting - Units Received1 Unit = 15 minutesWho Performed 97154?Please list first and last name of provider AND the number of units each provider performed.97154 - Group ABT by Protocol1 Unit = 15 minutesWho Performed 97158?Please list first and last name of provider AND the number of units each provider performed.97158 - Group ABT with Protocol Modification-Social Skills Group1 Unit = 15 minutesWho Performed 0373T?Please list first and last name of provider AND the number of units each provider performed.0373T - Units Received1 Unit = 15 minutesIs there another date of service for this patient? Yes No Date of Care* MM slash DD slash YYYY Care ReceivedPlease select ALL the codes this patient received on this date. 97151-Assessment 97152-Follow-up Assessment 97153-ABT 97155-ABT with Protocol Modification-Supervision 97155-ABT with Protocol Modification-Solo 97156-Family ABT Guidance 97156 AM - Team Meeting 97154 - Group ABT by Protocol 97158 - Group ABT with Protocol Modification-Social Skills Group 0373T - ABT with Protocol Modification - 2 Technicians Who Performed 97151?Please list first and last name of provider AND the number of units each provider performed.97151 - Units Received1 Unit = 15 minutesWho Performed 97152?Please list first and last name of provider AND the number of units each provider performed.97152 - Units Received1 Unit = 15 minutesWho Performed 97153?Please list first and last name of provider.97153 - Units Received1 Unit = 15 minutes97153 - Adjusted Units to BillWho Performed 97155 Supervision?Please list first and last name of provider.97155 Supervision - Units Received1 Unit = 15 minutesWho Performed 97155 Solo?Please list first and last name of provider AND the number of units each provider performed.97155 Solo - Units Received1 Unit = 15 minutesWho Performed 97156 Family ABT Guidance?Please list first and last name of provider AND the number of units each provider performed.97156 Family ABT Guidance - Units Received1 Unit = 15 minutesWho Performed 97156 AM Team Meeting?Please list first and last name of provider AND the number of units each provider performed.97156 AM - Team Meeting - Units Received1 Unit = 15 minutesWho Performed 97154?Please list first and last name of provider AND the number of units each provider performed.97154 - Group ABT by Protocol1 Unit = 15 minutesWho Performed 97158?Please list first and last name of provider AND the number of units each provider performed.97158 - Group ABT with Protocol Modification-Social Skills Group1 Unit = 15 minutesWho Performed 0373T?Please list first and last name of provider AND the number of units each provider performed.0373T - Units Received1 Unit = 15 minutesIs there another date of service for this patient? Yes No Date of Care* MM slash DD slash YYYY Care ReceivedPlease select ALL the codes this patient received on this date. 97151-Assessment 97152-Follow-up Assessment 97153-ABT 97155-ABT with Protocol Modification-Supervison 97155-ABT with Protocol Modification-Solo 97156-Family ABT Guidance 97156 AM - Team Meeting 97154 - Group ABT by Protocol 97158 - Group ABT with Protocol Modification-Social Skills Group 0373T - ABT with Protocol Modification - 2 Technicians Who Performed 97151?Please list first and last name of provider AND the number of units each provider performed.97151 - Units Received1 Unit = 15 minutesWho Performed 97152?Please list first and last name of provider AND the number of units each provider performed.97152 - Units Received1 Unit = 15 minutesWho Performed 97153?Please list first and last name of provider.97153 - Units Received1 Unit = 15 minutes97153 - Adjusted Units to BillWho Performed 97155 Supervision?Please list first and last name of provider.97155 Supervision- Units Received1 Unit = 15 minutesWho Performed 97155 Solo?Please list first and last name of provider AND the number of units each provider performed.97155 Solo- Units Received1 Unit = 15 minutesWho Performed 97156 Family ABT Guidance?Please list first and last name of provider AND the number of units each provider performed.97156 Family ABT Guidance - Units Received1 Unit = 15 minutesWho Performed 97156 AM Team Meeting?Please list first and last name of provider AND the number of units each provider performed.97156 AM - Team Meeting - Units Received1 Unit = 15 minutesWho Performed 97154?Please list first and last name of provider AND the number of units each provider performed.97154 - Group ABT by Protocol1 Unit = 15 minutesWho Performed 97158?Please list first and last name of provider AND the number of units each provider performed.97158 - Group ABT with Protocol Modification-Social Skills Group1 Unit = 15 minutesWho Performed 0373T?Please list first and last name of provider AND the number of units each provider performed.0373T - Units Received1 Unit = 15 minutesIs there another date of service for this patient? Yes No Date of Care* MM slash DD slash YYYY Care ReceivedPlease select ALL the codes this patient received on this date. 97151-Assessment 97152-Follow-up Assessment 97153-ABT 97155-ABT with Protocol Modification-Supervison 97155-ABT with Protocol Modification-Solo 97156-Family ABT Guidance 97156 AM - Team Meeting 97154 - Group ABT by Protocol 97158 - Group ABT with Protocol Modification-Social Skills Group 0373T - ABT with Protocol Modification - 2 Technicians Who Performed 97151?Please list first and last name of provider AND the number of units each provider performed.97151 - Units Received1 Unit = 15 minutesWho Performed 97152?Please list first and last name of provider AND the number of units each provider performed.97152 - Units Received1 Unit = 15 minutesWho Performed 97153?Please list first and last name of provider.97153 - Units Received1 Unit = 15 minutes97153 - Adjusted Units to BillWho Performed 97155 Supervision?Please list first and last name of provider.97155 Supervision- Units Received1 Unit = 15 minutesWho Performed 97155 Solo?Please list first and last name of provider AND the number of units each provider performed.97155 Solo- Units Received1 Unit = 15 minutesWho Performed 97156 Family ABT Guidance?Please list first and last name of provider AND the number of units each provider performed.97156 Family ABT Guidance - Units Received1 Unit = 15 minutesWho Performed 97156 AM Team Meeting?Please list first and last name of provider AND the number of units each provider performed.97156 AM - Team Meeting - Units Received1 Unit = 15 minutesWho Performed 97154?Please list first and last name of provider AND the number of units each provider performed.97154 - Group ABT by Protocol1 Unit = 15 minutesWho Performed 97158?Please list first and last name of provider AND the number of units each provider performed.97158 - Group ABT with Protocol Modification-Social Skills Group1 Unit = 15 minutesWho Performed 0373T?Please list first and last name of provider AND the number of units each provider performed.0373T - Units Received1 Unit = 15 minutesWere these charges performed via telehealth?* Yes No Other? If other, please explain.NotesAny additional comments?
