Call Us: 502-409-7181
Please submit this form with your IRF form (i.e., the BIG red button). Click on the little red button above to download the authorization form. This is only used for your co-pays and cost shares, we will review this and the IRF form as well as conduct an assessment during the complimentary screening.
SUBMIT THIS FORM WITH YOUR CONTACT FOR ANY COMMERCIAL INS REQUEST (Anthem, Tricare, UHC, Humana, Value Options, Cigna)
1.) Fill out "Contact Form for Screenings" (on top left of this page)
2.) Click the "RED Button" directly above
3.) Fill out "IRF" (PDF form)
4.) Fax the "IRF" (form) 1-888-450-0935
5.) Fax a copy "front/back of your primary & secondary INS CARD" 1-888-450-0935 (please send both cards front & back).
6.) Fax a copy of "diagnostic report" showing an autism diagnosis 1-888-450-0935 (state requires an autism diagnosis for commercial INS). Passport patients are not required to have an autism diagnosis.
8.) Fax a copy of the "prescription for ABA services" from the physician (if you have one)... 1-888-450-0935
7.) You can upload information and click "Submit" (on the left) to send in any non-PHI information, faxing the info. will be secure. Call the office 1-502-409-7181, ask for Insurance Screenings, we'll help you get this together and schedule a complimentary screening to learn about your ABA service needs.
Faxing these forms and submitting your screening request will make for a speedier process...
Download IRF form and upload for Commercial INS
CONTACT FORM FOR SCREENINGS
Our team offers scheduled brief intake screenings, service planning that includes several evaluation(s) of behavioral concerns, question/answer session and review of services offered, as well as behavior health assessment with initial goals and objectives.
1.) Fill out all fields (on left)
2.) Choose funding source, if unsure, check OTHER
3.) Indicate who referred you to CBA services
4.) Submit your request with all required fields completed (see IRF forms below "red button")
5.) We'll contact you after we receive the contact form for screenings (on left), remember to follow instructions below under "red button" if you have commercial insurance!
Clinical Behavior Analysis or CBA