Private Insurance referral form - Port Saint Lucie, Palm City, Fort Pierce | Behavior Basics, Inc.

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Date
School/Daycare Name
School/ Daycare Contact Person Name & Phone
Child’s Name
Address
Child DOB
Child Age
Child Gender
Child SS#
Insurance ID Number
Insurance Group Number
Policy Start Date
Policy Holder Employer Name
Co-Pay Amount:
Deductibles
Max Out of Pocket:
Employer Address:
Policy Holder Name
Policy Holder DOB
Policy Holder Social Security
Parent/Caregiver contact number
Parent/Caregiver Name
Child’s Diagnosis
Date of Original Diagnosis
Name & Phone of Physician providing Diagnosis
Behavior Concerns:
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**Notes: Please send with the referral any of the documents below as per carrier guidelines:

A copy of the front and back of your insurance card.
Detailed developmental and medical history, including medical records from prior clinicians or doctors including your last pediatric visit
Developmental, Cognitive and Neurological evaluation
List of Current Medications and prescribing physician
Adaptive behavior assessment
Medical history including, injuries, hospitalizations, surgeries, co morbid medical diagnosis, and allergies