CCABA - Diagnosis Report Submission

ASD Diagnosis Report Submission
Parent/Guardian Information:
Name*
Email*
Phone Number*
Format: (000) 000-0000.
ASD Diagnosis Report
A diagnosis of autism using a psychological evaluation and diagnostic test that includes the following information is required for services by insurance:
- Diagnosis Code F84.0 (Autism Spectrum Disorder) and a date of diagnosis
- DSM Severity Level of Autism
- The diagnostic tool/test used to make the diagnosis (ADOS, CARS, etc.)
- Medical provider signature with the credentials of MD, PhD, PsyD
- Testing administered by schools and other school documents (e.g., IEPs) typically do not meet the minimum requirements
Please Upload a Copy of your Child's ASD Diagnosis Report*

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