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Eligibility Verfication Form

Please complete the form with all the required details to serve you better.

Parent Details

Parent Full Name *

Phone Number *

Email *

Address *

Region *

City *

State *

Zip *

Second Parent / Guardian (if applicable)

Parent Full Name

Phone Number

Address

Region

City

State

Zip

Patient Information

Patient Full Name *

Patient DOB *

Age *

Gender *

Male Female

Member ID *

Group # *

Subscriber Information

Full Name *

Subscriber DOB *

Place of Employment *

Insurance Information

Insurance Company *

Insurance Phone # *

Other Insurance *

Insurance Self Funded *

Yes No

Front of Insurance Card *

UPLOAD

Back of Insurance Card *

UPLOAD

Note: Copy of Medical Insurance Card need to be attached for insurance verification.

Medical Information

Prescribing Physician Name *

Diagnosis *

Other Notes *

Diagnosis Report *

UPLOAD

Prescription of ABA Services *

UPLOAD

Note: In order to receive Applied Behavior Analysis (ABA) services, eligible individuals must have a valid ASD diagnosis. We require all pages of the comprehensive diagnostic report.
Autism diagnoses is a must to qualify for Medical ABA insurance eligibility.

Preferred Time Slots

Please select your region and city to view the available timeslot.

Service Location

Availability

Are you available for services Monday - Friday? (if no, please specify which days you are available)

Do you anticipate any availability changes over the next 6 months?

Are you working with any ABA providers?(Note: Only 1 assessment/authorization can be placed at a time)

Communication Mode

Referral Source

Search Engine (Google,Yahoo,Bing)

Social Media

Available Hours Per Week

Please select the available hours per week for your treatment session.

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