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Appendix 5.1

Extended Service Hours Request Rubric

Active clinic: [Company]

Use this rubric to document the clinical justification for services delivered before 7:00 AM, after 8:00 PM, on weekends, or on holidays. Each section must be completed and supported by data before the request is reviewed and approved by the supervising BCBA or designated clinical leadership.

Client and Staff Information
Requested Schedule
Clinical Justification
Functional Relevance
Data-Based Support
Standard Hours Review
Caregiver Participation
Safety and Clinical Impact
Compliance Verification
Analyst Attestation

I attest that this request is clinically appropriate, supported by available documentation and data, and consistent with medical necessity requirements and organizational standards.

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