Eligibility Verification Form

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

NOTE:

  • 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 - 3PM 30 days Wait Time 2PM - 4PM 40 days Wait Time 5PM - 7PM 40 days Wait Time 3PM - 6PM is Wait Time. (60 Days and above). 

    Second Parent / Guardian (if applicable)
    Patient Information
    Gender
    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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