Client Online Enrollment

Please complete the HIPAA compliant Riley ABA & Autism Center Enrollment form. Fields marked with * are required.

Enrollment

  • Client First Name
  • Client Last Name
  • MM slash DD slash YYYY
  • Primary Insurance

  • Please list insurance carrier. We are currently in network with Aetna, Ambetter, Blue Cross Blue Shield, Cigna, and United Behavioral Health.
  • MM slash DD slash YYYY
    If you are planning to bill insurance, please provide the policy holder's DOB. This is required.
  • Contact Information

  • Files

  • 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.
  • Max. file size: 512 MB.
    Please use this option to upload a photo of the FRONT of your insurance card.
  • Max. file size: 512 MB.
    Please use this option to upload a photo of the BACK of your insurance card.