Contracted Provider Behavior Analysis Network Exception Request Form

Please note: This exception request form is available only to contracted providers who are requesting to add a practitioner to their existing contract. Out of Network providers interested in joining Sunshine Health's network must complete the Become a Provider form.

Contracted providers should attempt the following prior to submitting an Exception Request:

Assign any Sunshine Health/CMS members to an in-network practitioner
Engage Sunshine Health/CMS Case Management that can assist members/families locating and coordinating with another in-network provider
Contact Sunshine Health Customer Service for list of in-network BA providers
Utilize the Find a Provider Tool to identify additional in-network providers

Contracted Provider Information

Provider (Group) Name *

TIN (Tax Identification Number) * Please no dashes "-"

Group National Provider Identifier (GNPI) *

Region *

Servicing County *

Name of Practitioner Exception Requested * Please no numbers

Name of Practitioner Exception Certification Type (BCBA, BCaBA or RBT) *

Exception Practitioner NPI *

Exception Practitioner Supervisor Name *

Reason for Exception Request (Select all that apply) * Provider serves specialized populations, such as deaf/hard of hearing individuals/American Sign Language (ASL) Provider specializes in complex medical needs Practitioner on Medical/Maternity Leave Significant waitlists No availability

Impacted Member Information

Number of Impacted Members *

Member Full Name *

Member ID *

Diagnosis *

Anticipated Member Start Date of Service (DOS) *

Member’s City *

Member’s County *

Request Submitted By

Submitter Name *

Submitter Title *

Submitter Email *

Submitter Phone *

Date Submitted *

Required Attachments

LOAP (Excel spreadsheet) *

Case details/justification (PDF document) *

Clinical supporting documentation (PDF document) *

Other

Please note all requests will be reviewed by Sunshine Health within 30 days to determine if an exception needs to be made. The goal is to ensure members are serviced by in-network providers who have been through the credentialing and onboarding process.