Patient Consent Form

Patient Information

Last Name *

First Name *

Middle Name

Date of Birth *

Age *

Gender *

Street Address *

Town *

State *

Zip Code *

Diagnosed as Autism Specturm Disorder by Dr *

at Age *

Doctor referring for ABA services; Name (copy) *

Phone

Insurance Information of Patient Covered by the Following Legal and Financial Responsible Party

Primary Insurance

Subscribers Name *

Date of Birth *

Insurance Company *

ID# *

Group# *

Claim Address *

Claim Phone No *

Secondary Insurance

Subscribers Name

Date of Birth

Insurance Company

ID#

Group#

Claim Address

Claim Phone No

Parent/Guardian Completing Form

Name *

Phone *

Email *

Attach Insurance Card Copy

Front

Click or drag a file to this area to upload.

Back

Click or drag a file to this area to upload.

Consent and Release

I hereby consent to treatment by, and authorize insurance benefits to be paid directly to Autism Spectrum Mandate Services. I agree that I am responsible to pay for services not covered by my insurance company, co-payments and deductibles, and for any expense associated with the collection of a debt owed to them. I also consent to the release of pertinent medical insurance information to my insurance carrier(s) for the purpose of processing health care claims. *

I agree

Date *

Witness *

Website