ABA Medicaid Only Today's Date* Date Format: MM slash DD slash YYYY Patient Name* First Last Phone*Email* Clinic*Choose a ClinicDreamShip CenterMilestones Behavioral PediatricsTrio AcademyMedicaid Insurance Coverage Insurance Company is Forward Health Medicaid. Patient has active coverage with Forward Health. Forward Health is the only insurance on file. Patient has regular Forward Health coverage for ABA therapy (full coverage) as primary. For ABA therapy, patient will not have any deductible, co-pays, or co-insurance due. Prior authorization is required for ongoing ABA therapy with Forward Health. To note: If patient does not have an autism diagnosis, it is possible that the Forward Health prior authorization may not be approved. It is up to the clinic to decide if they want to begin care with this patient before the prior authorization is approved. 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.