Request ABA Services
LEARNER INFORMATION
Learner Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Male
Female
N/A
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Has the member received a medical diagnosis of Autism Spectrum Disorder?
*
Yes
No
Has the member received a medical diagnosis of Down Syndrome?
*
Yes
No
Has the member received a medical diagnosis of Fetal Alcohol Syndrome?
*
Yes
No
Diagnosis was provided by (Physician Name and Office Name)
Please list any additional diagnoses:
Requested Service:
*
Morning ABA, 8:00 - 12:00 at Pilot Office
Morning ABA, 9:00 - 3:00 at Pilot Office
Afternoon ABA, 1:00 - 5:00 at Pilot Office
Morning ABA, 9:00 - 2:00 at PilotOffice
Afternoon ABA, 3:00 - 6:00 at Pilot Office
School / Daycare
Social Skills Groups
School / Daycare Information
Please provide name and address
*All ABA programs are Monday through Friday
Pilot Office:
731 Pilot Road Suite L Las Vegas, NV 89119
PARENT / GUARDIAN INFORMATION
Parent / Guardian Name:
*
First Name
Last 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
*
-
Month
-
Day
Year
(Parent/Guardian for Primary Insurance)
Member ID Number
*
Group Number
Does the Learner have a secondary insurance coverage?
*
Yes
No
Secondary Insurance Company
*
(i.e. Anthem BCBS, Culinary, Nevada Medicaid FFS, SilverSummit, etc.)
Subscriber Name
*
(Parent/Guardian for Secondary Insurance)
Subscriber Date of Birth
*
-
Month
-
Day
Year
(Parent/Guardian for Secondary Insurance)
Member ID Number
*
(Secondary Insurance)
Group Number
(Secondary Insurance)
Additional Notes:
How did you hear about us?
*
Please Select
Ackerman Center
ATAP
Community Event / Resource Fair
Current / Previous Member
Insurance
FEAT
Social Media
Upload Insurance Card
*
Browse Files
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Upload Diagnosis Document / Referral
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Upload IEP (if applicable)
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Submit
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