Skip to content

Client Online Enrollment

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

Enrollment

  • Client First Name
  • Client Last Name
  • Date Format: MM slash DD slash YYYY
  • Primary Insurance

  • Please list insurance provider. If you do not have insurance, please put "none".
  • Date Format: MM slash DD slash YYYY
    If you are planning to bill insurance, please provide the policy holder's DOB. This is required.
  • If you are a Tricare beneficiary, please list your Member ID #. This is required.
  • Secondary Insurance

  • Date Format: MM slash DD slash YYYY
    Please list secondary insurance provider and policy holder's DOB.
  • Contact Information

  • Your login information will be sent to this address
  • Files

  • 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.
  • 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.
  • Please use this option to upload a photo of the FRONT of your insurance card.
  • Please use this option to upload a photo of the BACK of your insurance card.
  • Please use this option to upload a photo of the FRONT of your secondary insurance card.
  • Please use this option to upload a photo of the BACK of your secondary insurance card.