Refer a Client to Opus ABA
Complete this secure referral form for in-home and center-based ABA therapy in Aberdeen, South Dakota.
Referring Provider / Clinic Name
*
Contact Person
Provider / Clinic Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Provider / Clinic Email
*
example@example.com
Provider / Clinic Fax
Patient Full Name
*
First Name
Last Name
Patient Date of Birth
*
-
Month
-
Day
Year
Date
Parent / Guardian Name
*
Parent / Guardian Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Language
Diagnosis with ICD-10 Code
Reason for Referral
Insurance Carrier
Please Select
Avera
Sanford Health Plan
SD Medicaid
Wellmark BCBS
Other
Member ID
Upload prescription/order for ABA, diagnostic evaluations, and insurance card
Upload a File
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I confirm I am authorized to share this patient information for the purpose of referral.
*
I confirm I am authorized to share this patient information for the purpose of referral.
Submit Referral
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