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.

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

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