Eligibility Verification Form

Please complete this form in its entirety so we can better serve you
Note: Autism diagnosis (F84.0) is a requirement to qualify for Medical ABA insurance eligibility

Patients Name

First Name

Last Name

Patients Date of Birth

YYYY

Patients Insurance Type

Patients Policy Number

Diagnosing Physician

Diagnosis

Date of Diagnosis

YYYY

Parent/Subscribers Name

Subscribers Date of Birth

YYYY

ABA Coverage for Autism?

Yes

Is this your only type of coverage?

Yes

Address

Phone Number

Which are you interested in?

In Home

In Clinic

Preferred Time Slots?

Daytime

Evenings

Weekends

Eligibility Verification FormPlease complete this form in its entirety so we can better serve youNote: Autism diagnosis (F84.0) is a requirement to qualify for Medical ABA insurance eligibility