Kindly provide the details below

Provider First Name

Provider Last Name

Name of Practice

Practice Phone Number

Practice Fax Number

Practice Email Address

Practice City

Practice State

Point of Contact First Name

Point of Contact Last Name

Client's First Name

Client's Last Name

Client's Date of Birth

Diagnosis Received? Diagnosis Received? Yes No

ASD (F84.0) ASD (F84.0) Yes No

Additional Diagnoses

Primary Concerns Primary Concerns Behavioral Adaptive Skills Social Skills Caregiver Training

Additional Comments

Caregiver First Name

Caregiver Last Name

What is their Relationship to the Client?

Caregiver Phone No

Caregiver Email Address

Caregiver City

Caregiver State

Caregiver ZIP / Postal Code

Hopeful Horizon Payors Hopeful Horizon PayorsAetnaAnthemBeaconBlue Cross Blue ShieldCarelonChampVACignaCommunity Health choiceFridayHumanaMagellanMedicaidMolina HealthcareOscarOptumSuperior HealthPlanTricareUnited HealthcareOther Commercial Insurance

Is Your Insurance Listed? Is Your Insurance Listed? Yes No