Getting Started

Application for Home and Center Based Hourly ABA Therapies

Incomplete or illegible applications and /or applications submitted without an attached diagnosis report and referral letter cannot be processed.

Application for Home and Center Based Hourly ABA Therapies (#4)

Hourly Therapy Options

(Please select all that apply AND include estimated hours and times preferred per week) *minimum of 4 hours / week required

Hourly Therapy Options

IN HOME

AT CHILDS SCHOOL / DAYCARE

ON SITE AT OUR LONGWOOD LOCATION

Number of hours per week In Home

Days & Times In Home

Number of hours per week At School / Daycare

Days & Times At School / Daycare

Number of hours per week At Our Longwood Location

Days & Times At Our Longwood Location

Client Information

Last Name

First Name

Address Line 1

Address Line 2

City

State

Zip Code

Age

Date of Birth

Sex

Male

Female

Social Security Number

Primary diagnosis

Date diagnosed

Diagnosing physician

Age at diagnosis

Secondary diagnosis

Date diagnosed

Diagnosing physician

Age at diagnosis

Current school attending (put "N/A" if not attending)

Funding Information

Funding source(s) for therapy (select all that apply/ attach documentation):

Family Empowerment Scholarship

VPK/SIS

Health insurance

Private pay

Other

Annual Funding Amount

Funding Amount

ID Number

Must attach approval letter

Choose File

Must Attach Comprehensive Diagnostic Report

Choose File

Must Attach Physician Referral

Choose File

Must Attach Front Insurance Card

Choose File

Must Attach Back Insurance Card

Choose File

Must attach award letter

Choose File

Must attach ID card image

Choose File

Primary Insurance Information

Insurance company

Policy holder name

Date Of Birth

Policy number

Group number

Phone number for providers

Secondary Insurance Information

Insurance company

Policy holder name

Date Of Birth

Policy number

Group number

Phone number for providers

Additonal Information

Peanut allergy?

Yes

Does child have an epi-pen?

Yes

Other Allergies?

Yes

If yes, please list

Currently taking medication?

Yes

If yes, please list

Current / previous therapies tried?

Yes

If yes, please list

Does child exhibit any behavior that would be considered dangerous to himself or others?

Yes

Please Explain

Responsible Party

Primary

Last Name

First Name

Age

Date Of Birth

Sex

Male

Female

Relationship to client

Social Security Number

Main Phone/Mobile

Secondary Phone/Mobile

Secondary

Last Name

First Name

Age

Date Of Birth

Sex

Male

Female

Relationship to client

Social Security Number

Main Phone/Mobile

Secondary Phone/Mobile

Emergency contact

Last Name

First Name

Relationship to client

Main Phone/Mobile

Expectations for ABA therapy

Patient Release & Acknowledgement

I verify that the information I have provided is correct to the best of my knowledge

I authorize the release of medical information necessary to receive benefit information, treatment authorization and in order for ABC to process claims through insurance companies and their agencies.

I have attached a diagnosis report AND the referral form from my childs medical doctor

I have completed all required portions of this document and understand that incomplete or illegible

Full name of insured or authorized person

Date / Time

I consent to have this website store my submitted information so they can respond to my inquiry

Application for Home and Center Based Hourly ABA Therapies

Hourly Therapy Options

Client Information

Funding Information

Primary Insurance Information

Secondary Insurance Information

Additonal Information

Responsible Party

Primary

Secondary

Emergency contact

Patient Release & Acknowledgement

Company

Contact Info

The first step to getting started is to complete this application.

The application must be completed entirely to verify eligibility and benefits.