Waiting List.xlsx

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Waiting List.xlsx

Parent's Name *

Child's Name *

Age *

Birth date *

YYYY

Street Address *

City and Zip *

City name, Zip Code

Phone Number *

Email *

Diagnosis *

ASD

AD/HD

None

Other:

Required

Funder *

If Medicaid, who manages the Plan?

Sunshine Health

CMS

Simply Healthcare

Humana

CCP/HN1

Clear selection

# Medicaid or Insurance Number

Primary Concerns *

Gender Preference

Male

Female

No Preference

Is the child enrolled in school or daycare? *

Yes

Name of School Child Attends

Does the child have an IEP?

Yes

Maybe

Clear selection

Referral from Pediatrician *

Yes

Comprehensive Diagnostic Eval or Equivalent *

Have you recently received ABA services? *

Yes

Client Availability: *

Parent Availability

Explain parent could be meeting with BCBA once a week

How did you hear about us?

Referring Physician *

How do you prefer to be contacted? *

Phone Call

Text

Required

Physician NPI or Medicaid #

Search http://www.npinumberlookup.org/ to find NPI and search http://portal.flmmis.com/FLPublic/Provider_ProviderServices/Provider_ProviderSupport/Provider_ProviderSupport_ClaimNPI/tabId/133/Default.aspx to confirm that they are a Medicaid Provider

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