Insurance Verifications

First Name*:

Last Name*:

Patient's First Name:

Patient's Last Name:

Phone Number*:

Patient's Phone Number (if different):

Address Line 1:

Address Line 2:

City:

State:

Zip:

Birth Date (YYYY-MM-DD):

Patient's Birth Date (YYYY-MM-DD):

Gender: FemaleMale

Email:

Parent/Guardian 1 First Name:

Parent/Guardian 1 Last Name:

Legal Guardian Address:

Marital Status: SingleMarriedSeparatedDivorcedWidowed

How did you hear about us?:

Parent/Guardian 2 First Name:

Parent/Guardian 2 Last Name:

Parent/Guardian 2 Address:

Parent/Guardian 2 Phone:

Parent/Guardian 2 Email:

Insurance Company:

Insurance Phone Number (on back of card):

Policy Number:

Group Number:

Plan Type:

Policy Holder's Name:

Policy Holder's Employer:

Policy Holder's Date of Birth (YYYY-MM-DD):

What is your child’s diagnosis?:

Is there secondary insurance? YesNo

If yes, what is it?:

Do you consent to Family Priority contacting your insurance carrier in order to determine the type and amount of funding that may be available for ABA services?: YesNo

Name of person filling out form:

Today's Date (YYYY-MM-DD):

Click here to upload proof of insurance (PDF files only; limit of 8MB):