Insurance Eligibility & Benefits Form

Purpose: The purpose of this form is to obtain your insurance information so that our team may contact your insurance team, and obtain specific insurance eligibility and benefits information for the specific care you requested. If your insurance information changes after this form has been submitted to us, please email us at intake@theautismimpactcircle.com to update your information.

Once we've obtained your eligibility and benefits information, we will forward it to you for your review, along with additional instructions regarding next steps. Eligibility and benefits inquiries are a courtesy, all information obtained should be verified by the policyholder.

If you need help filling out this form, please contact us at intake@theautismimpactcircle.com or via phone at (510) 910-4449.

Client Full Name

Client Date of Birth (DOB)

Date

Client Phone

Client Email

example@example.com

Client Address

Client's Relationship to Insured?

Self Child Spouse Other

Insurance Carrier

Insurance Phone Number (typically found on the back of your insurance card):

Insurance ID #

Primary Subscriber's Name (if different from above)

Primary Subscriber's DOB (if different from above)

Primary Subscriber's Mailing Address (if different from above)

I First Name Last Name provide consent to The Autism Impact Circle, to contact my insurance company, and request/obtain my insurance eligibility and benefits information, as outlined above.

Insured Signature

Clear

Date Signed

Clear

Please upload a picture of the front and back of your child's insurance card

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Insurance Eligibility & Benefits Form

Client Information:

Medical Insurance Information:

Consent