ABA Initial Assessment Report Template for Florida Medicaid (Word)
What it is for
An editable Word template for the initial behavior assessment and behavior plan. It follows the order of section 6.2.2 of Florida Medicaid's coverage policy (December 2024): patient information and referral, history, interview, file review, the core instruments, a table for each objective, caregiver training, units, supervision, coordination, transition, crisis and discharge plans, and the signatures. You fill it in on your computer; nothing is uploaded.
What it includes
- 16 sections in the order of section 6.2.2
- A 10-field table for each objective
- Tables for the instruments, caregiver training, units and supervisors
- Signature block for the Lead Analyst and the parent or guardian
- What to add at each six-month reassessment
- Word file and a printable PDF
How to use it
- Download the Word file and open it in your word processor.
- Replace every bracketed prompt with your findings and copy the objective table once per target, goal or objective.
- Attach the complete scoring reports of the core instruments to the authorization request.1
- Review the document, sign it and have the parent or guardian sign the assessment and the plan.1
What the template follows
- The parts of the assessment and behavior plan listed in section 6.2.2 of the December 2024 coverage policy.1
- The core instruments of the initial assessment: the Vineland-3 for all recipients and the BASC-3 PRQ for ages 2 through 18.1
- A plan period of up to six months, with a reassessment at least every six months.1
Before you send it
Questions about the tool
Is this an official Florida Medicaid form?
No. Florida Medicaid's coverage policy lists what the assessment and the plan must contain, and this template puts those parts in order. Check whether your health plan asks for its own form.
Where should I keep the filled-in report?
In your records system, like any clinical document. Once filled in, it holds client information, so keep it out of email drafts and shared folders.
Does it fill anything in for me?
No. Every section has a bracketed prompt that you replace with your own findings. You review, edit and sign the result.
Sources
- Florida Medicaid Behavior Analysis Services Coverage Policy. Agency for Health Care Administration (AHCA), December 2024, Rule 59G-4.125, F.A.C.
- SMMC New Program Highlight: Behavior Analysis Services. Agency for Health Care Administration (AHCA), October 18, 2024.
Educational tool. It does not replace clinical judgment, legal advice or your payer’s rules. Always check the current version of each source.