Online Application - Riley ABA & Autism Center

Client Waiting List Application

NOTICE: Effective 2023: We are currently only serving children ages eighteen months to five years old at this time. In addition, we are no longer accepting Kansas Medicaid/Sunflower plans or TRICARE.

Enrollment

First Name*

Client First Name
Last Name*

Client Last Name
Birthdate*
MM slash DD slash YYYY
Gender*
How Did You Hear About Us?*
Diagnosing Physician*
Current ABA Service Provider
Primary Insurance
Primary Insurance*

Please list insurance carrier. We are currently in network with Aetna, Ambetter, Blue Cross Blue Shield, Cigna, and United Behavioral Health.
Primary Policy Holder's DOB*
MM slash DD slash YYYY

If you are planning to bill insurance, please provide the policy holder's DOB. This is required.
Contact Information
Parent/Guardian First Name*
Parent/Guardian Last Name*
Address
Street Address Address Line 2 City State ZIP Code
Main Contact Phone:*
Email*
Preferred Method of Communication*
Email permissions*
Files
Diagnostic Report*
Max. file size: 512 MB.
Please upload the full diagnosis report from a licensed medical professional (note: school evaluations are not recognized as a formal diagnosis for insurance purposes). Photo images of the report are not acceptable when submitted to insurance. Please upload the all pages of the report as a PDF. This is a required document.
Primary Insurance (Photo of FRONT)
Max. file size: 512 MB.
Please use this option to upload a photo of the FRONT of your insurance card.
Primary Insurance Card (Photo of BACK)
Max. file size: 512 MB.
Please use this option to upload a photo of the BACK of your insurance card.

Client Waiting List Application

Enrollment

Primary Insurance

Contact Information

Files