NOTE: This form only needs to be submitted once per client. If you’ve already submitted one, you do not need to resubmit.
Please Include
1. FULL REPORT FROM DIAGNOSING PHYSICIAN (DEVELOPMENTAL PEDIATRICIAN OR PEDIATRIC NEUROLOGIST) EITHER ORIGINAL OR MOST CURRENT. MUST HAVE DIAGNOSIS ON DOCUMENT WITH PHYSICIAN’S NAME.
2. PRESCRIPTION FOR ABA THERAPY.
3. PLEASE PROVIDE US A COPY OF INSURANCE CARD FRONT AND BACK