Clone of GSAC-RF-(Section 1)

Comprehensive treatment
for children with
autism spectrum disorder.
Welcome to GulfSouth Autism Center’s Enrollment Packet.

Whether you are a new family joining us for the first time or a returning family continuing your child’s journey with us, we truly appreciate the opportunity to partner with you in supporting your child’s growth and development. This packet is required for all families and helps us keep your child’s information accurate and up to date.

What You Will Need
The following items are required to complete enrollment. Please have them ready to upload:

For all families (new and returning):
- Front and back of child’s insurance card
- Your child’s immunization records
- Photo ID of the parent or legal guardian
For new families only:
- Diagnostic evaluation for Autism Spectrum Disorder (ASD)
How This Form Works
- This packet may take some time to complete.
- You may use the Save & Continue feature to pause and return later if needed.
- The form cannot be submitted until all required fields and uploads are completed.
- If you experience any difficulty submitting the form, it usually means a required field or upload is missing. Please review each tab to complete any required items before submitting.
Our goal is to make this process as clear as possible and easy for parents to navigate. Please email or call with any question or challenges and we will be happy to assist:

(504) 229-0123
info@gulfsouthac.com
This registration is for:

First NameLast Name
Preferred GSAC location:
Are you a new or existing client?
Your selection will determine whether a diagnostic evaluation upload is required later in this registration form.

The following information is provided for reference and explains what qualifies as an acceptable diagnostic evaluation for insurance and clinical purposes.

General Requirements for All Insurance Types

Evaluations must be completed by a licensed, qualified clinician
Diagnosis aligns with DSM-5 criteria for Autism Spectrum Disorder (ASD)
Includes parent/caregiver interview and developmental history
Includes direct observation of the child (in person or virtual)
Includes review of any previous records or reports
Includes a written report or clinical note (screenings alone are not sufficient)
Includes a clear recommendation for or against ABA therapy

Additional Notes for Specific Insurance Types

Medicaid members:

Must meet Comprehensive Diagnostic Evaluation (CDE) requirements
May include ASD or another qualifying condition
May include recommendations for additional services

Commercial insurance members:

Autism-specific standardized testing
Adaptive behavior assessment
Cognitive evaluation (baseline functioning)
Written psychological report with test scores and findings
Documentation that other conditions were considered and ruled out

Medicaid vs. Commercial Insurance Comparison

Requirement	Medicaid	Commercial
Licensed, qualified clinician	✔	✔
DSM-5 ASD diagnosis	✔	✔
Parent/caregiver interview	✔	✔
Direct observation	✔	✔
Review of prior records	✔	✔
Autism-specific standardized testing	—	✔
Adaptive behavior assessment	—	✔
Cognitive evaluation	—	✔
Written diagnostic report	✔	✔
ABA recommendation required	✔	✔
Other conditions ruled out	—	✔

EMERGENCY CONTACT INFORMATION
Patient Name:

First NameLast Name
DOB:

MonthDayYear
Date
Primary Phone #:
Please enter a valid phone number.Format: (000) 000-0000.
Patient Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Caregiver 1’s Name:

First NameLast Name
Home Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Relationship to Patient
Caregiver 2’s Name:

First NameLast Name
Home Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Relationship to Patient
Additional Emergency Contacts
Contact 1's Name:

First NameLast Name
Address
Relationship to Patient
Work Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Contact 2’s Name:

First NameLast Name
Address
Relationship to Patient
Work Phone:
Please enter a valid phone number.Format: (000) 000-0000.
In case of emergency, who do we call first?
If forced to secure emergency medical treatment, my child’s pediatrician and dentist is:
Pediatrician’s Name

First NameLast Name
Practice/Group Name
Office Phone #:
Please enter a valid phone number.Format: (000) 000-0000.
Other Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Office Address:
Dentist’s Name:

First NameLast Name
Practice/Group Name

First NameLast Name
Office Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Other Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Office Address:
CHILD “PICK-UP" AND RELEASE POLICY
For the safety of your child, as well as that of the GulfSouth Autism Center, he/she cannot and will not be released into the custody of, or allowed to be picked up by, anyone other than the person or persons designated in writing by you. As an added precaution, if the person picking up your child cannot be identified by staff as an officially designated pick-up person, a request for identification may be made. Please inform your designated pick-up people that identification may be required and to be prepared, rather than insulted. In such a case, it is better to be safe and risk insult than it is to be wrong and compromise the safety of the child.
In addition, it is your responsibility to keep your designated pick-up list current. Any revisions to your official list, whether it be to add or delete from, must be in writing prior to the anticipated date of change.

With this in mind, I/we authorize the individuals listed below to pick up my/our child(ren) from the clinic, in addition to the designated caregivers and emergency contacts listed above:

Rows	Name	Relationship
1
2
3
4

Signature of Caregiver/Legal Guardian
Date

MonthDayYear
Date

FINANCIAL POLICY AND INFORMATION FORM
Patient Name:

First NameMiddle NameLast Name
Patient's DOB:

MonthDayYear
Date
Patient's Social Security #
Patient's Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
- Guarantor's Name
- Guarantor's Relation to Patient
- Guarantor's DOB
  
  MonthDayYear
  Date
- Guarantor's Social Security #
- Guarantor's Email
  example@example.com
- Guarantor's Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Guarantor's Phone (C):
  Format: (000) 000-0000.
- Guarantor's Phone (H):
  Format: (000) 000-0000.
- Guarantor's Phone (W):
  Format: (000) 000-0000.
- Guarantor's Employer:
- Guarantor's Employment Address:
- Would you be using Insurance?
- Primary Insurance Carrier:
- Policy #:
- Group #:
- Policy Holder’s Name:
- Policy Holder's DOB:
  
  MonthDayYear
  Date
- Policy Holder's Social Security #:
- Do you have Secondary Insurance?
- Secondary Insurance Carrier:
- Policy #:
- Group #:
- Policy Holder’s Name:
- Policy Holder's DOB
  
  MonthDayYear
  Date
- Policy Holder's Social Security #:
- Financial Obligations:
  
  An estimate of weekly financial obligations will be provided for you as a courtesy of GulfSouth Autism Center, under separate cover.
  
  This information is based on the coverage and benefits quoted by your insurance carrier and is not a guarantee of payment, only an estimated cost of treatment. Insurance may cover some of these procedures but is unlikely to cover all of them, as most policies have specific exclusions. Some services may be denied due to medical necessity, limited or absent authorization, or other policy limitations/exclusions. You should be aware that you will be responsible for the cost of any services provided by GulfSouth Autism Center that your insurance provider does not agree to cover, as well as any co-payments, co-insurance and deductibles.
  
  All payments are due at the time of service unless otherwise arranged with GulfSouth Autism Center’s billing supervisor. Services may be postponed or terminated due to outstanding balances. Due to the complicated nature of the pre-authorization process, we are happy to contact your insurance provider on your behalf to determine what your policy will cover and what out of pocket expenses you would incur. If you fail to make payments in a timely manner and your account must be forwarded to collections, you will be responsible for any additional charges associated with this.
  
  Change in Policy and/or Lapse of Coverage:
  
  It is your responsibility to notify GulfSouth Autism Center of any changes to your insurance policy, including but not limited to changes in insurance carrier, coverage, or home address. Timely communication of these updates is essential to ensure accurate billing. In the event of a lapse in coverage or termination of your insurance, you are required to inform GulfSouth Autism Center immediately. This will allow us to coordinate with you to create a plan to ensure there is no interruption of services for your child. Please be advised that any services provided by GulfSouth Autism Center during a period of uninsurance will be the financial responsibility of the guarantor.
  
  GulfSouth Autism Center reserves the right to collect any outstanding balances resulting from such gaps in coverage.
  
  Assignment of Benefits:
  
  I assign all benefits and rights to which I am entitled, and which are otherwise payable to me under any and all insurance contracts, self-insured programs or from any third-party payer and authorize and direct that payment of such be made directly to GulfSouth Autism Center or a GulfSouth Autism Center Provider, for services rendered. This assignment shall include the authority and right to institute legal action to recover all amounts due as a result of said services including any and all statutory penalties which may also be claimed and collected.
  
  Acknowledgement and Agreement:
  
  By signing below, I acknowledge that I have read, understood, and agree to abide by the financial policies of GulfSouth Autism Center as outlined above. I authorize GulfSouth Autism Center to use and disclose the protected health information (PHI) provided in this form to my insurance provider for the purposes of obtaining coverage for services, processing payments, or conducting utilization reviews.
  
  I understand that the benefit information provided by my insurance carrier is not a guarantee of payment, and that all claims are subject to the terms and conditions of my specific insurance policy. As such, coverage for services rendered by GulfSouth Autism Center is not guaranteed and may not be paid by my insurance provider.
  
  I further acknowledge that I am responsible for payment of any services that are not covered or reimbursed by my insurance provider. This authorization and agreement shall remain in effect indefinitely, unless all outstanding balances for services rendered are paid in full.
- Signature of Individual or Personal Representative by Law
- Date & Time:
  
  MonthDayYear
  Date
  Hour MinutesAM/PM Option
- Printed Name of Individual or Personal Representative by Law
- Relationship to Child

ACKNOWLEDGEMENT AND AGREEMENT TO NON-COVERED SERVICES
Patient’s Name:

First NameLast Name
Patient’s Date of Birth:

MonthDayYear
Date
I,
Name of person filling the form
Acknowledge that I have been informed that certain portions of (the patient's) therapy may not be covered by my insurance. These portions may include and are not limited to (initial each below)
Name of patient
Check All That Apply
Monthly Supply Fee: $40.00 per month
Phone calls and in office meetings lasting longer than 15 minutes: $45 per 15 minutes ($180 per hour)
Communications with and responding to correspondence from other Physicians: $45 per 15 minutes ($180 per hour)
Travel time required by a Registered Line Technician (e.g., ABA Therapist): $22.50 per 15 minutes ($90 per hour)
Travel time required by a GulfSouth Autism Center Provider (SLP, LBA, LP, etc.): $45 per 15 minutes ($180 per hour)
Letters regarding treatment/recommendations/accommodations/disability, etc.: $140 per letter
Nonapproved/covered record review and report writing for initial assessment, re-assessment, treatment planning, or behavioral consultation: $45 per 15 minutes ($180 per hour)
A rush request for the completion of reports/letters/accommodations, etc. < 2 weeks: $400
A rush request for the completion of reports/letters/accommodations, etc. 2 – 3 weeks: $250
You should be aware that you will be responsible for the cost of any procedures that your insurance does not agree to cover as well as all co-payments and deductibles. All payments are due at the time services are rendered. If you fail to make payments in a timely manner and your account must be turned over to collections, you will be responsible for all associated charges. By signing below, you are verifying that you have carefully read and understand the statements and charges above and agree to the terms described.
Signature of Responsible Party
MonthDayYear
Date
Printed Name of Responsible Party
Relationship to Patient
Signature of Responsible Party
MonthDayYear
Date
Should be Empty:

Comprehensive treatment
for children with
autism spectrum disorder.

Please Upload the Following:

Who lives with your child? (names, relationships to child, and ages):

EMERGENCY CONTACT INFORMATION

Additional Emergency Contacts

If forced to secure emergency medical treatment, my child’s pediatrician and dentist is:

CHILD “PICK-UP" AND RELEASE POLICY

ALLERGY INFORMATION

FINANCIAL POLICY AND INFORMATION FORM

ACKNOWLEDGEMENT AND AGREEMENT TO NON-COVERED SERVICES

Comprehensive treatmentfor children withautism spectrum disorder.