Insurance Verification Form
We are happy to check your ABA/Autism benefits. This is a no pressure, complimentary service. By completing this forms I understand, and agree to release my protected health information to Focused Behavior Solutions, LLC and companies working on their behalf.

To verify insurance benefits, please complete this form and provide a copy of your primary insurance ID card. Forms may be emailed to admin@focusedbehaviorsolutions.com, or faxed to 208-620-3985. Please allow 3 business days for verification of your insurance.



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Email *
Child's Name *
Parent/Guardian's Name *
Parent/Guardian's Phone number *
Best way to reach you *
Today's Date *
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Location: *
Date of Birth *
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Child's Gender *
Address (Street, City, Zip) *
Primary Diagnosis *
Primary Care Physician *
PCP Phone Number *
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