Enrollment Form

*

First NameLast Name

Gender

Date of Birth*

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Does student have a prescription for ABA services?*

YesNo

How did you hear about us? Referred by: .

First NameLast Name

Phone Number

Please enter a valid phone number.

Email*

example@example.com

Name of Diagnosing Physician

Physician Phone Number

Please enter a valid phone number.

Insurance Primary Policyholder

First NameLast Name

Date of Birth

Date

Relationship to Student

MotherFatherSelfOther

Insurance Provider

If 'Other', please specify

Insurance ID

Insurance Card Front

Insurance Card Back

Hours Available for ABA Services (select all that apply)

MorningAfternoonEvening

Days Requesting Services (select all that apply)

IMPORTANT: Before we can verify your coverage with your insurance company, we need a copy of the front and back of your insurance card. Please scan or snap a picture of both sides and submit them in this form or to info@starbrightaba.com. If you require assistance, please call us at 845-863-5208 or email us.

A quote of benefits and/or authorization does not guarantee payment. Payment of benefits is subject to all terms, conditions, limitations, and exclusions of the member’s contract at the time of service. *** You will always be solely responsible for letting your provider know about any changes in insurance and or payment status for services. Any services not fully covered by insurance will be the responsibility of the patient/family.

Privacy Disclaimer: StarbrightAba will never sell your information to any third party person we are committed to protecting your personal information and your right to privacy.

Enrollment Form

Contact Information

Student Information

Primary Caregiver Information

Referral / Insurance Information