CABS New Client Application

APPLICATION FOR SERVICES

Complete the form below in its entirety. Anything with an asterisk (*) is required.
Clinic Location*

Itasca, ILRome, GASavannah, GAStatesboro, GA

Parent or Legal Guardian 1 Information
Is your child 18 years or older?*

YesNo
Do you have legal guardianship of your child?*

YesNo
Please provide a copy of your guardianship paperwork to ensure that you have the legal right to medical and financial decisions and responsibility for your child.

Cancelof
Full Name*
Relationship to Child*
Age*
Address (only if different than applicant)
City (only if different than applicant)
State (only if different than applicant)
Zip Code (only if different than applicant)
Email*
example@example.com
Occupation*
Name of Employer*
Home Phone (or main phone number)*
Business Phone
Cell Phone*

Health Insurance Information
PRIMARY POLICYHOLDER INFORMATION

Please note that the policy holder for Medicaid and other CMO's is often the minor child and not the parent/caregiver.
Name*
DOB*
Relationship to Child*

MotherFatherGuardianSelfOther
PRIMARY INSURANCE INFORMATION
Primary Insurance Carrier*
Plan Type*
Group Name/Employer*
Case Manager Name and Contact # (if applicable).
Authorization # (if applicable)
Please upload photo of the front of your insurance card*
Please upload photo of the back of your insurance card*

SECONDARY INSURANCE INFORMATION

Clients who have a secondary insurance (including Medicaid) but fail to notify CABS may be responsible for copays and deductibles. Failure to pay these may result in reporting to collections and may negatively affect your credit.
Do you have secondary insurance?*

YesNo
Policy Holders Name*
Policy Holder's DOB*
Relationship to Child*

MotherFatherGuardianSelfOther
Secondary Insurance Carrier*
Plan Type*
Group Name/Employer*
Case Manager Name and Contact # (if applicable).
Authorization # (if applicable)
Photo of the front of your secondary Insurance card (if applicable)
Photo of the back of your secondary Insurance card (if applicable)
PLEASE ADD ANY OTHER IMPORTANT INSURANCE INFORMATION HERE (if applicable):

I authorize Chicago Autism and Behavior Specialists (CABS) to release and receive information from the above-identified insurance company for the purpose of verifying insurance benefits for services that CABS may provide to applicant.

Once authorization is received, I consent for CABS to conduct an intake assessment on above named client. I understand that consent for assessment is not consent for treatment or a guarantee of ongoing treatment.
Parent/Guardian Signature*

Clear
Date of Submission*

MonthDayYear
Date
Should be Empty:

APPLICATION FOR SERVICES