+1-305-787-2924
Request ABA Therapy
  • Español

Intake Process

What documents are required?

In order to check the benefits, we will need to collect the following info/documents:

  1. Basic demographic information for the parent/caregiver and individual who will receive the services.
  2. In addition, you will have the opportunity to upload pictures of your insurance card (front and back), and
  3. Any diagnostic reports verifying a qualifying diagnosis.

To obtain authorization for services based on the individual’s current need we will need to obtain the following documents:

  1. Referral for ABA Services. The referral must include a physician’s order for behavior analysis services. The referral must contain the client’s diagnostic and ICD 10 Code.

The recipient must be referred to by an independent physician or practitioner qualified to assess and diagnose disorders related to functional impairment, including:

  • Primary care physician with family practice, internal medicine, or pediatrics specialty
  • Board certified or board eligible physician with specialty in developmental behavioral pediatrics, neurodevelopmental pediatrics, pediatric neurology, adult or child psychiatry
  • Child psychologist.
  1. Letter of medical necessity.
  2. Comprehensive diagnostic evaluation (CDE) performed according to national evidence-based practice standards.

CDEs may be performed by a multidisciplinary team or individual practitioner. In any case, the CDE must be led by a licensed practitioner working within their medical, developmental, or psychological scope(s) of practice. The CDE must include assessment findings and treatment recommendations appropriate to the recipient.

  1. Previous medical documentation from pediatrician, Neurologist, IEP or 504 from Public School.
  2. Signed consent

Our clinical team will then work to evaluate the referral and obtain an authorization for services based on the individual’s current benefits. Our team will contact us to provide a status update.

Apply now
1
Client
2
Parent/Guardian Information
3
Your Availability
4
Reason for Referral
5
Payment Source
6
Diagnosis
7
Last Page

Client Information

Legal First Name *
Preferred First Name *
Middle Initial
Legal Last Name *
Date of Birth *
Gender *
Referred By *
Has the client received ABA services in the past year? *

Parent/Guardian Information

Email *
First Name *
Middle Name
Last Name *
Date of Birth *
Street Address *
State *
Postal Code *
County *
Home Phone *
Work Phone
Mobile Phone *

Availability and Setting

What days and times would work best for you?

Setting (Choose one or more) *
Availability (Choose one or more) *

Reason for Referral / Primary Concerns

Reason for Referral / Primary Concerns (Check all that apply) *
Caregiver Comments / Examples of Concerns
Do you have a type of Medicaid Insurance? *
Medicaid Name *
Medicaid #
Medicaid Card FRONT Upload
Maximum file size: 5 MB
Upload your Medicaid card images (FRONT) *(jpeg, jpg or png)
Medicaid Card BACK Upload
Maximum file size: 5 MB
Upload your Medicaid card images (BACK) *(jpeg, jpg or png)
Do you have a type of Commercial Insurance? *
Company Name *
Card Holder Name *
Date of Birth *
Last 4 digit of insured SSN *
Member Number *
Group Number *
Commercial Insurance Card Upload FRONT Upload
Maximum file size: 5 MB
Upload your Commercial Insurance card images *(jpeg, jpg or png)
Commercial Insurance Card BACK Upload
Maximum file size: 5 MB
*(jpeg, jpg or png)
Do you consent to a partial telehealth option if available *
Initial consent to services *

Thank you for your interest. To begin working with you and provide services, we need your permission to contact you and evaluate your documentation. Please select “Yes” to give your consent. Without it, we won’t be able to move forward. Let us know if you have any questions.

By signing below, you authorize JZ Advanced Behavior Services, Inc. to use your signature and the information provided in this application to conduct ABA assessments, develop treatment plans, and submit all required documentation to your insurance provider. This includes requests for authorizations, re-authorizations, progress reports, and any materials necessary to obtain or maintain coverage for ABA services.  

Draw Your Signature *
Clear

Diagnosis

Upload your doctor’s referral with the current diagnosis

Child's Diagnosis (choose one or more) *
One or more diagnosis images
Maximum file size: 6 MB
*Max. 3 images (jpeg, jpg or png, pdf)
Upload Other Documents
Maximum file size: 5 MB
*Max. 3 images (jpeg, jpg or png, pdf)
Name of the doctor that diagnosed your child *
Date of Diagnosis

Language

Primary language spoken

Select language *
What is your primary Language spoken? *