ABA Commercial Only Today's Date* MM slash DD slash YYYY Patient Name* First Last HiddenPhone*HiddenEmail* Clinic*Choose a ClinicDreamShip Center - CameronDreamShip Center - Eau ClaireMilestones Behavioral PediatricsTrio AcademyPrimary Insurance CoverageName of Insurance Company Clinic isChooseIn NetworkOut of NetworkInsurance Coverage for these codes: 97151 Behavior Identification Assessment 97152 Behavior Identification Supporting Assessment 97153 ABT by protocol 97155 ABT with protocol modification 97156 Family ABT guidanceIn Network BenefitsIndividual Deductible - Amount per yearHow much individual deductible left to meet for this year?DeductibleChooseRuns on a calendar yearRuns on a plan yearPlan year runs fromMonth/Day to Month/Day Family Deductible - Amount per yearHow much family deductible left to meet for this year?Co-insurance/co-pay that patient must pay per visitAfter deductible is met:Choose% of the allowed in network rateDollar amountBoth co-insurance and co-pay dueNo co-insurance/co-pay dueCo-insurance - % of the allowed in network rate? Co-pay - Dollar amount?Individual Out of Pocket - Amount per yearOnce a patient has met their out of pocket for the year, the patient's co-pay or co-insurance will no longer apply.How much individual out of pocket left to meet for this year?Family Out of Pocket - Amount per yearOnce a patient has met their out of pocket for the year, the patient's co-pay or co-insurance will no longer apply.How much family out of pocket left to meet for this year?Is prior authorization required for ABA therapy? Yes No Out of Network BenefitsIndividual Deductible - Amount per yearHow much indvidual deductible left to meet for this year?DeductibleChooseRuns on a calendar yearRuns on a plan yearPlan year runs fromMonth/Day to Month/Day Family Deductible - Amount per yearHow much family deductible left to meet for this year?Co-insurance/co-pays that patient must pay per visitAfter deductible is met:Choose% of the charged amountDollar amountBoth co-insurance and co-pay dueNo co-insurance/No co-pay dueCo-insurance - % of the charged amount? Co-pay - Dollar amount?Individual Out of Pocket - Amount per yearOnce a patient has met their out of pocket for the year, the patient's co-pay or co-insurance will no longer apply.How much individual out of pocket left to meet for this year?Family Out of Pocket - Amount per yearOnce a patient has met their out of pocket for the year, the patient's co-pay or co-insurance will no longer apply.How much family out of pocket left to meet for this year?Is prior authorization required for ABA therapy? Yes No *Note: Patient does not have Forward Health Medicaid as secondary insurance.Additional CommentsDisclaimer When we call on a patient's insurance and verify benefits it is not a guarantee of payment by the insurance company and may vary according to the patient's individual plan when the actual claim is submitted. Payment of benefits are subject to all terms, conditions, limitations, and exclusions of the member's contract at time of service. The patient responsibility amount provided is an estimate of cost. The patient must understand that their health insurance company may deny payment for the services received. The patient must understand that it is ultimately the patient's responsibility to contact their insurance if they want to know exact benefits.NameThis field is for validation purposes and should be left unchanged. Δ
