Insurance Verification Request for ABA & Speech Therapy
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Email address *
How did you first hear about us? *
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Parent Last Name *
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Parent First Name *
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Primary Phone Number *
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Secondary Phone Number *
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Street Address *
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City *
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State *
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Zip Code *
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Child's Last Name *
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Child's Middle Initial *
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Child's First Name *
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Child's Date of Birth *
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Diagnosis (If your child has not been diagnosed, please type "NA") *
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Diagnosing Doctor or Professional's Name (If your child has not been diagnosed, please type "NA") *
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Name of Insurance Company (If you don't have insurance, please type "NA." If you don't know the date, please type "don't know.") *
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Telephone number on back of insurance card for providers to call *
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Policy ID Number *
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Policy ID Group Number *
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Primary Card Holder Name *
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Primary Card Holder Date of Birth *
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Any other information that could be helpful: *
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