Online Application - Riley ABA & Autism Center

Client Online Enrollment

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

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*
Referring Physician
Current ABA Service Provider
Primary Insurance
Primary Insurance*

Please list insurance provider. If you do not have insurance, please put "none".
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.
Tricare Member ID#

If you are a Tricare beneficiary, please list your Member ID #. This is required.
Insurance Holder’s Employer
Secondary Insurance
Secondary Insurance & Policy Holder's DOB
MM slash DD slash YYYY

Please list secondary insurance provider and policy holder's DOB.
Contact Information
Parent/Guardian First Name*
Parent/Guardian Last Name*
Address*
Street Address Address Line 2 City State ZIP Code
Cell Phone*
Home Phone
Work Phone
Email*

Your login information will be sent to this address
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.
ABA Prescription
Max. file size: 512 MB.
Please upload your prescription for ABA therapy on a script pad stating your child needs ABA therapy. If you have Tricare you will not need a prescription. If the diagnosis report recommends ABA therapy, you will not need a separate prescription.
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.
Secondary Insurance (Photo of FRONT)
Max. file size: 512 MB.
Please use this option to upload a photo of the FRONT of your secondary insurance card.
Secondary Insurance (Photo of BACK)
Max. file size: 512 MB.
Please use this option to upload a photo of the BACK of your secondary insurance card.

Client Online Enrollment

Enrollment

Primary Insurance

Secondary Insurance

Contact Information

Files