Eligibility Verification Form

1 Step 1

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


  • Autism diagnoses is a must to qualify for Medical ABA insurance eligibility.
  • Medical Insurance Card front and back image need to be attached for insurance verification.
  • 8AM - 12PM  No Wait Time |  12PM - 3PM No Wait Time. 
  • 2PM - 7PM (60+ Days Wait Time for all regions except East Contra Costa Region).

    Second Parent / Guardian (if applicable)
    Patient Information
    Subscriber Information
    Insurance Information
    Insurance Self Funded
    Medical Information
    Preferred Time Slots
    Please check the time slots your child is available for sessionsNote: The requested time slot cannot be chaged for at least 6 months.
    Referral Source
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    Get in Touch With Us

    To speak with our ABA Treatment Experts, Call 866-375-AGES(2437)

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