Achievement Behavior Services Patient Information

Student Name*

First NameLast Name

Date of Birth*

MonthDayYear

Gender*

MaleFemaleOther

Primary Caregiver Name*

First NameLast Name

Best Number to Reach You?*

Area CodePhone Number

What is the best time for us to give you a call?

E-mail*

If we can't reach you by phone can we text you? *

I

Street Address*

Street Address Line 2

City*

State / Province*

Students address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Postal / Zip Code*

Does student have a medical ASD diagnosis?*

#2 Responsible Caregiver Name

First NameLast Name

#2 Caregiver Phone Number

Area CodePhone Number

Name of Prescribing Physician*

Dr. Phone number

Area CodePhone Number

Where are you seeking ABA services

Hours available for ABA services (*10 hour minimum required)

Days Requesting Services (*4 days a week preferred)

How did you hear about Achievement Behavior Care Services (allow us to thank them)*

Have your child received ABA Services before

Please let us know past experiences below

Additional comments that you feel we should know, what do you feel your child needs help with the most right now?

Please provide us with any relevant information that you may feel is important

Primary person Policyholder *

name of caregiver with insurance

Relationship to Student*

MotherFatherSelfOther

Policyholder DOB*

Date

#1 Primary Insurance Provider*

If you don't see your insurance ..its fine :-)

OTHER insurance if not listed above

Insurance ID Primary number *

primary insurance

Group Number primary*

Insurance Phone Number

Area CodePhone Number

#2nd insurance *

please provide name of secondary insurance or NONE

#2 Insurance ID number

if applicable we require this information

2nd insurance Phone Number

Area CodePhone Number

Snap or upload photo of front of insurance card

Snap or upload photo of back of insurance card

Consent Signature*

Thank you for your application we will contact you within the next 24 hours.

IMPORTANT: Before we can verify your coverage with your insurance company, we need a copy of the front and back of your insurance card. Please scan or snap a picture of both sides and submit them here or email eperl@abcachieve.com If you require assistance, please call us at 516-229-1194 ext 207 or email us.

A quote of benefits and/or authorization does not guarantee payment. Payment of benefits is subject to all terms, conditions, limitations, and exclusions of the member’s contract at the time of service**you will always be solely responsible for letting your provider know about changes in insurance and/or payment status of services. Any services not fully covered by insurance will be the responsibility of the patient/ family/ caregiver

Privacy Disclaimer*Achievement Behavior will never sell your information to any third-party person we are committed to protecting your personal information and your right to privacy. please contact us at info@abcachieve.com if you have any questions

Privacy guarantee: We do not share your information and will contact you only as needed to provide our ABA service.

Insurance Information