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Phone

Child's Information

Child's Full Name

Child's Date of Birth

Child's Address

Primary Language/s Spoken

Primary Caregiver's Information

Primary Caregiver's Name

Relationship to Child

Address (if different than child)

Cell Phone Number

Behavioral Information

Please describe any specific challenging behaviors or concerns for which you are seeking ABA therapy:

Availability

Insurance Information

Primary Insurance

Policy Holder's Full Name

Relationship to Child

Policy Number

Group Number

Secondary Insurance Provider (if applicable)

Secondary Insurance Policy Number (if applicable)

Insurance Card Front: Please attach a copy of the front and back of your insurance card:

Diagnosis and Referral Information

Does your child have an ASD diagnosis?

Does your child have any other diagnosis?

Name of Diagnosing Physician

Physician Phone Number

Date of Comprehensive Evaluation

Autism Diagnosis Date (if different from above)

Does the child have a prescription for ABA therapy?

Comprehensive Evaluation: Please attach a copy of your child's comprehensive evaluation/assessment performed by their health care provider that led to a diagnosis:

ABA Prescription: Please attach a copy of your child's ABA prescription:

Authorization to Check Insurance Coverage for ABA Therapy

Authorization:

I, the undersigned parent or legal guardian of the child identified above, hereby authorize Little Chats Applied Behavior Analysis PLLC ("Little Chats) to obtain information regarding our insurance benefits for the purpose of verifying coverage and determining benefits related to Applied Behavior Analysis (ABA) services for our child.

Scope of Information:

This authorization includes the verification of coverage, the determination of deductibles, co-pays, and co-insurance, and the review of any pre-authorization or pre-certification requirements.

Release of Information:

I understand that this authorization allows Little Chats to communicate with my insurance provider to gather information related to my child's coverage and benefits for ABA services.

Duration of Authorization:

This authorization is valid as of the effective date below and extends for one calendar year, or throughout the period during which my child receives services from Little Chats. I understand that I have the right to revoke this authorization at any time by providing written notice to Little Chats. I also understand that any information obtained under this authorization will be used solely for the purpose of verifying insurance benefits for my child's ABA services.

Signature

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Date

Month

Day

Year