Eligibility Verification Form

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

Parent Full Name
Phone Number
Address
0 /
City
Zip
Second Parent / Guardian (if applicable)
Full Name
Phone Number
Address
0 /
City
Zip
Patient Information
Full Name
DOB
date_range
Age
Gender
Member ID
Group #
Subscriber Information
Full Name
DOB
date_range
Place of Employment
Insurance Information
Insurance Company
Insurance Phone #
Other Insurance
Insurance Self Funded
Front of Insurance ID Cardupload
cloud_uploadUpload
Back of Insurance ID Cardupload
cloud_uploadUpload
Medical Information
Prescribing Physician Name
Diagnosis
Other Notes
Diagnosis Paperworkupload
cloud_uploadUpload
Prescription for ABA Servicesupload
cloud_uploadUpload
Preferred Time Slots
Please check the time slots your child is available for sessionsNote: This availability should be consistent for at least 8-12 months
Referral Source
How did you hear about us?
Other
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