Patient Registration Form

Autism Services Insurance Verification Request
Child's Name: (first/last) *
Date of Birth *

Month Day Year
Date
Gender
Parent/Guardian Name *
Phone Number *
Address *

Street Address

Street Address Line 2

City/State/Zip
Diagnosis *
Services Requested
Diagnosing Physician *
Date of Diagnosis

Month Day Year
Date
Diagnosing Physician Contact *
Primary Care Physician
Primary Care Physician Contact
Insurance Information

New Insurance Old Insurance Other
Subscriber's name
Subscriber's S.S. no.
Birth date

Month Day Year
Date
Policy no
Group No
Subscriber's Address
Employer
Patient's relationship to subscriber
Secondary insurance
Subscriber's name
Birth date

Month Day Year
Date
Subscriber's S.S. no.
Policy no
Group No
Subscriber's Address
Employer
Patient's relationship to subscriber
PLEASE INCLUDE A COPY OF THE FRONT AND BACK OF YOUR INSURANCE CARD
Financially Responsible Name *
Phone Number
Address
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorizeor insurance company to release any information required to process my claims
Patient/Guardian signature *

Clear
Date *

Month Day Year
Date
Should be Empty: