ABA Interest Form
Child Information
Child's Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
Gender
Parent/Guardian Contact
Parent/Guardian Name
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Has your child been diagnosed with autism spectrum disorder?
Yes
No
What improvements or changes would you like to see from ABA therapy?
Primary Insurance Information
Primary Insurance Carrier
*
Member ID
*
Policyholder Name
*
Policyholder Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Relationship to Child
*
Secondary Insurance Information
Secondary Insurance (if applicable)
Secondary Member ID #
Authorization & Consent
Authorization Acknowledgment
*
I authorize DESTINation Little Learners to release necessary medical and treatment information to my insurance carrier(s) for billing, verification, and authorization purposes, and I understand I am responsible for any non-covered services, copays, deductibles, or balances.
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Insurance Card Front
*
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Insurance Card Back
*
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Submit
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