Benefits Verification Form

Baucom Behavioral’s billing department determines your eligibility and benefits for ABA services by contacting your health insurance carrier. Verification of benefits for ABA services does not commit potential clients to services through Baucom Behavioral. We verify eligibility and benefits for ABA services as a courtesy to all potential clients. Fill in the fields below and we will contact you shortly to discuss your benefits.

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Name:*

Email:*

Insured's Full Name:*

Insured's Date of Birth:*

Insured's Address:*

Child's Full Name:*

Child's Date of Birth:*

Child's Diagnosis:*

Primary Phone Number:*

Secondary Phone Number:

Other Phone Number:

Insured's Employer:

Insurance Carrier:*

Insurance Carrier Phone Number:*

Insurance ID Number:

Front Copy/Photo of Insurance ID Card:

Acceptable file types: doc,pdf,txt,gif,jpg,jpeg,png.
Maximum file size: 1mb.

Back Copy/Photo of Insurance ID Card:

Proof of Diagnosis:

Prescription for ABA Services:

CAPTCHA Code:*