Florida Patient Form

Florida Patient Form
Caregiver Name*

First NameLast Name
How did you hear about us?*

GoogleFacebookProvider ReferralSchool or Day Care CenterFriend or FamilyDoctor or PediatricianInsurance CompanyOther
Name of the Full Spectrum ABA Provider that referred you:
Email
example@example.com
Phone Number*
Alternative Number
Type of Insurance*

MedicaidPrivate
Name of Insurance
Name of Private Insurance Company

Advent HealthAETNACIGNATRICAREOther
Our Team needs more information to check if we can provide ABA Therapy for your children. Please submit the form and we will contact you from 1-2 business days. Thank you.
Insurance ID
Insurance Subscriber Name (Policyholder)

First NameLast Name
Date of Birth of Insurance Subscriber (Policyholder)

MonthDayYear
Date
Patient's Name*

First NameMiddle NameLast Name
Patient's Date of Birth*

MonthDayYear
Date
Patient's Sex*

MaleFemale
County*

BradfordBrevardCharlotteCitrusDeSotoHamiltonHardeeHernandoHighlandsHillsboroughHolmesGainesvilleGilchristIndian RiverLakeLeeLeonLevyManateeMarionMonroeOcalaOrangeOsceolaPascoPinellasPolkSarasotaSeminoleSumterTaylorVolusiaWaltonOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Check all the behavioral concerns that apply to your child:*

ElopementPhysical AggressionTantrumTask RefusalSelf Injurious BehaviorProperty DestructionSpittingMouthing ObjectsDisrobingVerbal AggressionOther
Does the family speaks fluent English or primarily Spanish?

Fluent EnglishFluent SpanishOther
Diagnosis Code
The patient is currently attending:*

SchoolDay CareHome SchoolOther
Name of the Patient School or Day Care Center
Doctor's Name and Practice
Doctors' Office Phone Number
Doctor's Mailing Address
Delivery Method

MailPhoneFaxEmail
Choose "I Authorize ALL" or select individually

I authorize ALL Health information to be disclosedIndividual Education Plan (IEP)Psych Educ. AssessmentReport Cards/TranscriptsBehavioral ReportSpecial ReportPsychological EvaluationMedication Management VisitsSpeech/Language EvaluationHearing ScreeningMedical History and Immunization RecordNeurology ReportPsychiatric EvaluationProgress NotesClient Information SheetIndividualized TreatmentTreatment Plan ReviewsPsychosocial EvaluationBehavioral ProgramDischarge SummaryProgress Summary
Expiration

One YearTwo yearsType a Date: mm/dd/year
Purpose of the Release of Information

At the request of the IndividualAssessmentTreatment
Coordination

Disability DeterminationTo obtain information for Brief Behavioral Health Status ExamOther - Please Specify
1) I understand that Full Spectrum Behavior Analysis, LLC cannot guarantee that the Recipient will not re-disclose my health information to a third party. The Recipient may not be subject to federal laws governing privacy of health information. 2) I understand that I may refuse to sign this Authorization and that my refusal to sign will not affect my ability to obtain treatment from Full Spectrum Behavior Analysis, LLC. 3) I understand that I may revoke this Authorization in writing at any time, however, l cannot revoke authorization for action that has already been taken. I further understand that I must provide any notice of revocation in writing to the Business Office at the address listed above.
Copy of Insurance Card - FRONT and BACK

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I understand that the Physician’s referral (Script) must include:*

a) “ABA therapy" or "Applied Behavior Analysis"b) Diagnosis with the ICD10 diagnosis codec) Must be signed by an MD or DO.d) Physician’s namee) Script format (Not letter)
Physician’s referral (Script)

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I understand that the Comprehensive Diagnostic Evaluation must include:*

The full report used to officially diagnose the child.Most common evaluations are: ADOS-2, CARS2, CSBS, Neurological Evaluation, Psychological Evaluation, Psychiatric Evaluation, Vanderbilt Etc.Must be led by one of the following: Child Neurologist, Child Psychologist, Child Psychiatrist, or Developmental Pediatrician.
Comprehensive Diagnostic Report

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Client Availability for ABA Therapy
Would you like to add availability for ABA Therapy?*

Yes, this will help FSABA find a provider for my child.No, I will wait for a representative to call me to complete this information.
Availability Instructions:

Adding this information will help us find a provider.

HERE ARE SOME EXAMPLES. SCROLL DOWN TO COMPLETE FORM.

Example #1: The client is available From 8:30 am until 2:00 PM.

If you have multiple slots of availability on a day you can select more boxes.

Example #2:

From 9:00 AM to 12:00 PM

From 4:00 PM to 8:00 PM

If the client is not available on a certain day just select Not Available.

Example #3: Not available
Monday Availability

Not Available7:00 AM7:30 AM8:00 AM8:30 AM9:00 AM9:30 AM10:00 AM10:30 AM11:00 AM11:30 AM12:00 PM12:30 PM1:00 PM1:30 PM2:00 PM2:30 PM3:00 PM3:30 PM4:00 PM4:30 PM5:00 PM5:30 PM6:00 PM6:30 PM7:00 PM7:30 PM8:00 PM
Tuesday Availability

Not Available7:00 AM7:30 AM8:00 AM8:30 AM9:00 AM9:30 AM10:00 AM10:30 AM11:00 AM11:30 AM12:00 PM12:30 PM1:00 PM1:30 PM2:00 PM2:30 PM3:00 PM3:30 PM4:00 PM4:30 PM5:00 PM5:30 PM6:00 PM6:30 PM7:00 PM7:30 PM8:00 PM
P2P Date

MonthDayYear
Date
Fair Hearing Date

MonthDayYear
Date
Wednesday Availability

Not Available7:00 AM7:30 AM8:00 AM8:30 AM9:00 AM9:30 AM10:00 AM10:30 AM11:00 AM11:30 AM12:00 PM12:30 PM1:00 PM1:30 PM2:00 PM2:30 PM3:00 PM3:30 PM4:00 PM4:30 PM5:00 PM5:30 PM6:00 PM6:30 PM7:00 PM7:30 PM8:00 PM
Thursday Availability

Not Available7:00 AM7:30 AM8:00 AM8:30 AM9:00 AM9:30 AM10:00 AM10:30 AM11:00 AM11:30 AM12:00 PM12:30 PM1:00 PM1:30 PM2:00 PM2:30 PM3:00 PM3:30 PM4:00 PM4:30 PM5:00 PM5:30 PM6:00 PM6:30 PM7:00 PM7:30 PM8:00 PM
Friday Availability

Not Available7:00 AM7:30 AM8:00 AM8:30 AM9:00 AM9:30 AM10:00 AM10:30 AM11:00 AM11:30 AM12:00 PM12:30 PM1:00 PM1:30 PM2:00 PM2:30 PM3:00 PM3:30 PM4:00 PM4:30 PM5:00 PM5:30 PM6:00 PM6:30 PM7:00 PM7:30 PM8:00 PM
Saturday Availability

Not Available7:00 AM7:30 AM8:00 AM8:30 AM9:00 AM9:30 AM10:00 AM10:30 AM11:00 AM11:30 AM12:00 PM12:30 PM1:00 PM1:30 PM2:00 PM2:30 PM3:00 PM3:30 PM4:00 PM4:30 PM5:00 PM5:30 PM6:00 PM6:30 PM7:00 PM7:30 PM8:00 PM
Sunday Availability

Not Available7:00 AM7:30 AM8:00 AM8:30 AM9:00 AM9:30 AM10:00 AM10:30 AM11:00 AM11:30 AM12:00 PM12:30 PM1:00 PM1:30 PM2:00 PM2:30 PM3:00 PM3:30 PM4:00 PM4:30 PM5:00 PM5:30 PM6:00 PM6:30 PM7:00 PM7:30 PM8:00 PM
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Florida Patient Form

Client Availability for ABA Therapy