Benefit Verification Form
E-mail
example@example.com
Childs Name
*
First Name
Last Name
DOB
*
-
Month
-
Day
Year
Date
Child's Diagnosis, if any:
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Subscribers Name
First Name
Last Name
Subscribers DOB
-
Month
-
Day
Year
Date
Email address to send benefits information to:
example@example.com
Verification of Benefits (check all that apply)
ABA
Social Skills Group
Preschool (ABA)
Speech Therapy
Occupational Therapy
Please list any other therapies your child is currently receiving and by whom
Please attach a picture of the FRONT of your license
Browse Files
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Choose a file
Cancel
of
Please attach a picture of the FRONT of your insurance card
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Drag and drop files here
Choose a file
Cancel
of
Please attach a picture of the BACK of your insurance card
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Drag and drop files here
Choose a file
Cancel
of
If you have a secondary insurance, please attach a picture of the FRONT of the card.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
If you have a secondary insurance, please attach a picture of the BACK of the card.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit
Should be Empty: