Insurance Verification Form - Lumina Autism Center
21792
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Insurance Verification Form

    Client Insurance Verification Form


    (Fields marked with * are required.)


    How did you hear about us? *


    Parent/Guardian Information


    First Name *

    Last Name *

    Email *

    Phone *

    Alternate Phone

    Best way to contact *

    Best times to contact *


    Patient Information


    First Name *

    Last Name *

    Birth Date *

    Autism Diagnosis Date

    Diagnosed By

    Additional Diagnoses


    Address


    Street Address *

    City *

    State / Province / Region *

    ZIP / Postal Code *


    Insurance Information


    Insurance Name / Plan *

    Provider's Phone As Listed On The Back Of The Insurance Card*

    Policy Subscriber First Name *

    Policy Subscriber Last Name *

    Policy Subscriber Birth Date *

    Policy Subscriber ID *

    Policy / Group # *


    Copy of Primary Insurance Card *


    Copy of Medicaid Card (if available)


    ABA Prescription


    Diagnostic Report


    IEP (if available)


    If your documents exeed the upload limit, please send them through email.