Autism Health Coverage Intake Form

First Name :

Last Name :

Child's Diagnosis :

Child's Age :

City :

State :
Please Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip code :

Phone number (with area code) :

Email :

Insurance Company:

State in which plan was purchased:
Please Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Type of Plan:

PPO:    HMO:   

Individual Plan:    Employee Provided Plan:   

What services were requested (ABA/ST/OT/other)

What Services (if any) Were Granted:

What Services Were Denied:

Reasons Given for Denial:

Appeal Process Pursued (if any):

Current Status of Claim: