Florida Patient Form

Caregiver Name*

First NameLast Name

Email*

example@example.com

How did you hear about us?*

Name of the Full Spectrum ABA Provider that referred you:

Phone Number*

Alternative Number

Type of Insurance*

MedicaidPrivate

Name of Private Insurance Company

Name of Insurance

Our Team needs more information to check if we can provide ABA Therapy for your children. Please submit the form and we will contact you from 1-2 business days. Thank you.

Insurance ID

Insurance Subscriber Name (Policyholder)

First NameLast Name

Date of Birth of Insurance Subscriber (Policyholder)

Date

Patient's Name*

First NameMiddle NameLast Name

Patient's Date of Birth*

Date

Patient's Sex*

MaleFemale

Select your county*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Check all the behavioral concerns that apply to your child:

Does the family speaks fluent English or primarily Spanish?

Fluent EnglishFluent SpanishOther

Diagnosis Code

The patient is currently attending:*

SchoolDay CareHome SchoolOther

Name of the Patient School or Day Care Center

Doctor's Name and Practice

Doctors' Office Phone Number

Doctor's Mailing Address

Delivery Method

MailPhoneFaxEmail

Choose "I Authorize ALL" or select individually

Expiration

One YearTwo yearsType a Date: mm/dd/year

Purpose of the Release of Information

At the request of the IndividualAssessmentTreatment

Coordination

Disability DeterminationTo obtain information for Brief Behavioral Health Status ExamOther - Please Specify

1) I understand that Full Spectrum Behavior Analysis, LLC cannot guarantee that the Recipient will not re-disclose my health information to a third party. The Recipient may not be subject to federal laws governing privacy of health information. 2) I understand that I may refuse to sign this Authorization and that my refusal to sign will not affect my ability to obtain treatment from Full Spectrum Behavior Analysis, LLC. 3) I understand that I may revoke this Authorization in writing at any time, however, l cannot revoke authorization for action that has already been taken. I further understand that I must provide any notice of revocation in writing to the Business Office at the address listed above.

Florida Patient Form

Patient Information

OPTIONAL

Client Availability for ABA Therapy