• 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

  • Preferred GSAC location*
  • New or Existing Client?*

  • 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

    • Evaluation Guidelines 

    • 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 — ✔

  • Please Upload the Following

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    • Registration Information 
    • Date*
       / /
      2 digit month, 2 digit day, 4 digit year
    • Child Information 
    • Child's DOB*
       / /
      2 digit month, 2 digit day, 4 digit year
    • Child's Sex*
    • Family/Household Information 

    • Parents/Guardians

    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Is Parent/Guardian (1) address the same as Child's address?*
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Is Parent/Guardian (2) address the same as Patient's address?

    • Other Caregivers

      Please list anyone else who regularly cares for your child, such as a grandparent, adult sibling, babysitter, or nanny.
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.

    • Other Household Members

      Please list other household members not already listed above.

    • Additional Family Information

    • Medical Information 
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Are there any medical conditions we should be aware of (e.g., asthma, epilepsy/seizures)?*
    • Does your child have any food or environmental allergies?*
    • Does your child have any physical limitations?*
    • Does your child currently take routine medications? *
    • Has your child had a hearing screening/evaluation? *
    • Has your child had a vision screening/evaluation? *
    • Were there any prenatal concerns? *
    • Were there any postnatal concerns?*
    • Has your child ever been hospitalized?*
    • Has your child had any previous surgeries? *
    • Are there any concerns about nutritional status? *
    • Has your child ever had a swallow study (MBSS)?*
    • Has your child ever been placed on a feeding tube?*
    • Does your child have any dietary restrictions?*
    • Developmental and Social Information:  

    • Please provide the approximate age at which your child began to do the following activities (write N/A if the skill is not developed).

    • How does your child communicate their wants and needs?*
    • If your child uses verbal speech, how well can you understand their speech?*
    • Does your child echo words/sounds (echolalia, scripting)?*
    • Does your child imitate your actions?*
    • Does your child seek out interactions with others?*
    • Is your child toilet-trained?*
    • Does your child use a pacifier?*
    • Did your child have difficulty with any of the following?*
    • What does your child use to drink?*

    • Has your child ever received any of the services listed below?

    • Physical Therapy*
    • Ongoing?*
    • Start Date*
       / /
      2 digit month, 2 digit day, 4 digit year
    • End Date*
       / /
      2 digit month, 2 digit day, 4 digit year
    • Occupational Therapy*
    • Ongoing?*
    • Start Date*
       / /
      2 digit month, 2 digit day, 4 digit year
    • End Date*
       / /
      2 digit month, 2 digit day, 4 digit year
    • Speech Therapy*
    • Ongoing?*
    • Start Date*
       / /
      2 digit month, 2 digit day, 4 digit year
    • End Date*
       / /
      2 digit month, 2 digit day, 4 digit year
    • ABA Therapy*
    • Ongoing?*
    • Start Date*
       / /
      2 digit month, 2 digit day, 4 digit year
    • End Date*
       / /
      2 digit month, 2 digit day, 4 digit year
    • Psychological Services*
    • Ongoing?*
    • Start Date*
       / /
      2 digit month, 2 digit day, 4 digit year
    • End Date*
       / /
      2 digit month, 2 digit day, 4 digit year
    • Other Services
    • Ongoing?
    • Start Date*
       / /
      2 digit month, 2 digit day, 4 digit year
    • End Date*
       / /
      2 digit month, 2 digit day, 4 digit year
    • Other Services
    • Start Date*
       / /
      2 digit month, 2 digit day, 4 digit year
    • End Date*
       / /
      2 digit month, 2 digit day, 4 digit year
    • Other Services
    • Start Date*
       / /
      2 digit month, 2 digit day, 4 digit year
    • End Date*
       / /
      2 digit month, 2 digit day, 4 digit year
    • Behavioral Information 
    • Does your child engage in any behaviors that are difficult for one person to manage, or that require you to change your daily schedule or routine?*
    • How difficult are these behaviors for one person to manage?*
    • How often do these behaviors occur?*
    • Have these behaviors caused injury to your child or others?*
    • Social & Educational Information 
    • Has your child ever attended school, daycare, Mother’s Day Out, or similar program?*
    • Start Date*
       / /
      2 digit month, 2 digit day, 4 digit year
    • End Date*
       / /
      2 digit month, 2 digit day, 4 digit year
    • Has your child had an Early Steps Evaluation? *
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    • Has your child had a Pupil Appraisal Evaluation (e.g., Child Search)?*
    • Browse Files
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    • Does your child have an Individualized Education Program (IEP)?*
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    • Referral Information 
    • What are your primary reasons for seeking services? (Select all that apply)*
    • At the beginning of treatment, we’ll identify your child’s favorite items and activities that can be used during teaching (such as toys, snacks, music, or videos). Are there any items or activities your child should avoid (for example, due to dietary restrictions)?*

  • EMERGENCY CONTACT INFORMATION

  • Child's DOB*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
    • Parents/Guardians Information 
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.

    • Additional Emergency Contacts

    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • In case of emergency, who do we call first?*

    • In the event emergency medical or dental treatment is required, my child's providers are:

    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.

    • 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
    • Date*
       / /
      2 digit month, 2 digit day, 4 digit year

  • ALLERGY INFORMATION

  • Child's DOB*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Does your child have any known allergies?*
  • Does your child have food allergies?*
  • Does your child have medication allergies?*
  • Does your child have other allergies (for example, environmental or seasonal)?*
  • Does your child carry an EpiPen?*
  • Are there foods you prefer your child to avoid?*
  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year

  • INSURANCE & FINANCIAL INFORMATION

  • Child's DOB*
     / /
    2 digit month, 2 digit day, 4 digit year
    • Insurance Information 
    • Would you be using Insurance?*
    • Policy Holder's DOB*
       / /
      2 digit month, 2 digit day, 4 digit year
    • Do you have Secondary Insurance?
    • Policy Holder's DOB*
       - -
      2 digit month, 2 digit day, 4 digit year
    • Guarantor Information:  

    • The Guarantor is the person financially responsible for your child’s account and may be different from the Parent/Guardian completing this form, or the Insurance Policyholder.

    • Will someone other than you be the Guarantor?*
    • Guarantor's DOB*
       / /
      2 digit month, 2 digit day, 4 digit year
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.

    • 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 child’s 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 and/or the Guarantor are responsible for the cost of services not covered by your child’s insurance provider, as well as any applicable co-payments, co-insurance, deductibles, and other patient-responsibility amounts.

      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 child’s insurance provider on your behalf to determine what your child’s insurance coverage 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 child’s insurance coverage, 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 or termination of your child’s insurance coverage, 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 child’s 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 child’s insurance carrier is not a guarantee of payment, and that all claims are subject to the terms and conditions of my child’s insurance coverage. As such, coverage for services rendered by GulfSouth Autism Center is not guaranteed and may not be paid by my child’s insurance provider.

      I further acknowledge that I and/or the Guarantor are responsible for payment of any services that are not covered or reimbursed by my child’s insurance provider. This authorization and agreement shall remain in effect indefinitely, unless all outstanding balances for services rendered are paid in full.

       

    • Date*
       / /
      2 digit month, 2 digit day, 4 digit year

  • NON-COVERED SERVICES & FEES

  • Child's DOB*
     / /
    2 digit month, 2 digit day, 4 digit year

  • INTRODUCTION

    I have been informed and acknowledge that certain portions of my child’s therapy may not be covered by insurance.

    These may include, but are not limited to, the following non-covered services and associated fees:

    NON-COVERED SERVICES & FEES

    Service Fee
     Phone Calls / Office Meetings lasting longer than 15 minutes  $45 per 15 minutes
      ($180 per hour)
     Communications / Correspondence with Physicians, Schools, or Other Providers   $45 per 15 minutes
      ($180 per hour)
     Travel Time — Registered Line Technician (ABA Therapist, SLP, LBA, LPC, etc.)  $22.50 per 15 minutes
      ($90 per hour)
     Travel Time — GulfSouth Autism Center Provider (SLP, LBA, LPC, etc.)  $45 per 15 minutes
      ($180 per hour)
     Letters Regarding Treatment Recommendations / Accommodations /
    Disability    		  $140 per letter
     Non-Approved Record Review and Report Writing  $45 per 15 minutes
      ($180 per hour)
     Rush Request Completion within 2 weeks  $400
     Rush Request Completion within 2–3 weeks  $250


    FINANCIAL RESPONSIBILITY

    You and/or the Guarantor are responsible for the cost of services or procedures not covered by your child’s insurance provider, as well as any applicable co-payments, co-insurance, deductibles, and other patient-responsibility amounts.

    Payment is due at the time services are rendered unless other payment arrangements have been approved in advance.

    If your account is referred to collections due to non-payment, you will be responsible for all associated collection costs and fees.

    By signing below, you acknowledge you have read and understand the fees and financial responsibilities described above and agree to the terms outlined herein.


  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: