• Client Intake Form (Children Services)

    To best meet the needs of your family and loved one, please complete the information below. Provide as much information as possible, as this helps us know your individual and unique needs, and serve you quicker and better. Once completed and submitted, you will receive further information on the process, and our Lead BCBAs will be in touch with you. Thank you for trusting BMC with your needs.

  • Client Information

  • Client Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Is there a second guardian/point of contact*
  • Format: (000) 000-0000.
  • Preferred Service Location*
  • Requested Location of Service (check all that apply)*
  • Location of Service (check all that apply)*
  • Can the client verbally communicate*
  • Main Concern (check all that apply)*

  • Insurance, Diagnostics and Supporting Documentation

  • Primary Insurance (please note that we do not accept: Humana Medicaid, Florida Community Care Plan, Aetna Better Health Medicaid, CareSource, United Medicaid, AmeriGroup, Molina, Oscar, or CHAMPVA*
  • Primary Insurance*
  • Is the client a Family Support Services (FSS) client?*
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Do you receive funding through the "Step up for Students grant" (for Florida residents)"*

  • Private Pay Financial Agreement – SUFS

    Process
    To receive reimbursement through SUFS, parents will receive an invoice from BMC to be paid through the SUFS system. The parents are responsible for entering the billing information into their SUFS portal. When it is successfully entered into the system, BMC will be alerted the payment has been entered and submitted for our approval. Note: the process is now initiated by the parents, and this should be done as soon as possible following the receipt of the invoice from BMC. Families should expect this invoice to be sent through email on file to the parent. For use of SUFS for copay amounts, the invoice will be delivered to the family after the insurance processes the initial claim. For any questions about the SUFS system, please email Ms. Rhonda Luttrell at rluttrell@bmcsoutheast.com.

    As it will be noted in your award information, these grants extend from July 1 to June 30. As a result, claims for the prior fiscal year are due no later than July 31. Therefore, claims that are not in the SUFS system by that time may not be payable, so it is important to get the claim information in as soon as possible at this time of year. The family will be responsible for any claim that is not entered in a timely manner, resulting in a denial due to the lapse of time across fiscal years. Please see all information from your SUFS grant award regarding timely processing of claims for payment.

    Rates
    BMC is dedicated to quality services provided by quality providers at the level of experience and credentialing determined by the lead BCBA to be the most appropriate for successful delivery of Behavior Analysis services. Therefore, your BMC team may include several therapists with different levels of credentials and experience. Any specific names are listed as current options, but may change based on clinical need or other changes which will be communicated with the family at least 30 days in advance of the change.

    1. Lead/Consulting BCBA – $100/hr – Work conducted by the BCBA will include supervision of the RBT services at no less than 5% of scheduled RBT hours in addition to parent training, consultation with the RBT, data analysis and report writing.
    2. Direct RBT services - $50/hr – Work conducted by the RBT is direct and active treatment. There may be some time associated with data analysis, entry and programming, which will reduce the cost of the BCBA conducting such necessary work.

    **Data analysis and programming, as a necessary component of behavior analysis services, will be billed on an hourly basis either during times scheduled for therapy at the clinic/home, or off site a times not scheduled for therapy.

    Time, Method and Manner of Payment

    Invoices for services/copays will be done via email through QuickBooks Online where you can also make online payments. You will be able to do this by using a credit card or with a bank transfer from your checking account.

    The invoices you receive will not include what is being billed to your insurance company. Each invoice will list your copay amount and which month the copays correlate to. Once we receive payment from the insurance company, we can determine the amount of copay coinsurance owed. We will then invoice you for this amount. If you receive a copay invoice, and you have secondary insurance, let us know immediately. Invoices are due upon receipt, and late fees will be added if not paid timely. We will send eobs upon request.

    Your email from us with the invoice and/or statement will be from Behavior Management Consultants email address. It will also say in the subject line, Invoice from Behavior Management Consultants. If there is a particular email address you want these sent to, we recommend a personal email versus a work email, please email that information to bmcoffice@bmcsoutheast.com.

    *Following the first full month of services, please check your “spam filter” to make sure you are receiving your invoices. If not, please contact bmcoffice@bmcsoutheast.com.

  • Insurance - Secondary*

  • As secondary insurances process claims differently, we cannot guarantee BMC can file costs not covered by the primary insurance to the secondary insurance. However, we will do our best to explore this with you prior to services beginning.

  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Has your child undergone a diagnostic evaluation by a developmental pediatrician, child psychiatrist, child psychologist, or child neurologist?*

  • STOP: If your child does not have a formal diagnosis by a developmental pediatrician, child psychiatrist, child psychologist or child neurologist BMC will not be able to provide services. Please obtain this documentation prior to completing the rest of this form. 

    EXCEPTION: IF CHP WITH DIAGNOSIS OTHER THAN AUTISM YOU MAY NOT NEED DIAGNOSITIC EVALUATION

  • What is the client's diagnosis*

  • STOP: If your child does not have a formal diagnosis by a developmental pediatrician, child psychiatrist, child psychologist or child neurologist BMC will not be able to provide services. Please obtain this documentation prior to completing the rest of this form. 

  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Do you have a copy of a Doctor Referral for Applied Behavior Analysis? (All FL Medicaid Plans require an MD/DO Signature on the referral)**

  • STOP: If your child does not have a referral from a doctor for Applied Behavior Analysis BMC will not be able to provide services. Please obtain this documentation prior to completing the rest of this form. 

  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Are you currently receiving ABA services*
  • Have you received ABA services in the past*
  • Do you receive any other therapies*
  • Does the client attend school*
  • Does the client have an IEP*
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Does the client have a 504 plan*
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • What kind of classroom is your child in*
  • Does the client attend after school care*
  • Does the client attend day care*
  • Rows
  • Rows
  • Are you willing to deviate or have the ability to deviate from this schedule*
  • How did you hear about Behavior Managment Consultants*
  • 0/100
  • Should be Empty: