BX Fluency_Service Request

Request ABA Services
LEARNER INFORMATION
Learner Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender
Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Has the Learner received a medical diagnosis of Autism Spectrum Disorder?
Has the Learner received a medical diagnosis of Down Syndrome?
Has the Learner received a medical diagnosis of Fetal Alcohol Syndrome?
Diagnosis was provided by (Physician Name and Office Name)
Please list any additional diagnoses:
Session Location Preference
Clinic Location: 731 Pilot Road Suite L Las Vegas, NV 89119

*In-Home consultation required prior to acceptance. A responsible adult must be present for all ABA sessions that are conducted in home.

** Pre-Approval from School/Daycare required prior to acceptance.
Session Time Preference
Additional Notes:
If requesting services in school/daycare please provide the name and address
PARENT / GUARDIAN INFORMATION
Parent / Guardian Name:

First NameLast Name
Relationship to Member
E-mail
example@example.com
Phone Number:
Format: (000) 000-0000.
INSURANCE DETAILS
Primary Insurance Company
(i.e. Anthem BCBS, Culinary, Nevada Medicaid FFS, SilverSummit, etc.)
Subscriber Name
(Parent/Guardian for Primary Insurance)
Subscriber Date of Birth

MonthDayYear
(Parent/Guardian for Primary Insurance)
Member ID Number
Group Number
Does the Learner have a secondary insurance coverage?
Secondary Insurance Company
(i.e. Anthem BCBS, Culinary, Nevada Medicaid FFS, SilverSummit, etc.)
Subscriber Name
(Parent/Guardian for Secondary Insurance)
Subscriber Date of Birth

MonthDayYear
(Parent/Guardian for Secondary Insurance)
Member ID Number
(Secondary Insurance)
Group Number
(Secondary Insurance)
Additional Notes:
How did you hear about us?
Upload Insurance Card

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Upload Diagnosis Document / Referral

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FA-11F: Autism Spectrum Disorder (ASD) Diagnosis Certification for Requesting Initial Applied Behavior Analysis (ABA) Services

Required for Nevada Medicaid plans
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Upload IEP (if applicable)

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Should be Empty:

Request ABA Services

LEARNER INFORMATION

PARENT / GUARDIAN INFORMATION

INSURANCE DETAILS