Tools > Info Needed Report-ABA

Info Needed Report-ABA

  • 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.