CABS New Client Application

APPLICATION FOR SERVICES

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

Parent or Legal Guardian 1 Information
Is your child 18 years or older?
Do you have legal guardianship of your child?
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)
Format: (000) 000-0000.
Business Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.

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

Other
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?
Policy Holders Name
Policy Holder's DOB
Relationship to Child

Other
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