INSURANCE PREAUTHORIZATION REQUEST

We'd love to hear from you! Please fill out the form and we'll get back to you as soon as possible.

Patient Information

Child's Full Name *

Child Date of Birth *

Parent/Guardian Information

Guardian First Name *

Guardian Last Name *

Phone *

Email *

Requested Hours *

Primary Insurance Information

Primary Insurance Provider *

Policy Holder Full Name *

Policy Holder Date of Birth *

Subscriber ID *

Group # *

Secondary Policy Holder Full Name

Secondary Group #

Secondary Subscriber ID

Relationship to Patient

Back of Insurance Card *

Front of Insurance Card *

Required Documents

Autism Diagnosis Report *

Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB.Please upload a copy of your Autism DIAGNOSIS (IEP is not accepted by Insurance)

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health insurance portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize Gracious Growth ABA in the HIPAA Acknowledgement. to use and disclose my protected health information to carry out: Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment) Obtaining payment from third-party payers (e.g. my insurance company) The day-to-day healthcare operations of Gracious Growth ABA in the HIPAA Acknowledgement. I have also been informed of and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact Gracious Growth ABA in the HIPAA Acknowledgement. at any time to obtain the most current copy of this notice. I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment, and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction. I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.

Signature

Clear

Date Signed

Relationship to Child