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Eligibility and Benefits Consultation Inquiry Form
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* Indicates required question
What's your name?
*
Your answer
What's your email address?
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Your answer
What's the name of your agency?
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Your answer
What's your role in your agency? (Check all that apply.)
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Owner/Founder/CEO
Clinician (e.g., BCBA, SLP, LPC)
Biller/billing specialist
Other:
Required
What services does your agency provide? (Check all that apply.)
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Applied Behavior Analysis (ABA)/Behavior Therapy
Mental Health Counseling
Occupational Therapy
Speech and Langauge Therapy
Other:
Required
For which services are you wanting to use our eligibility and benefits consultation service? (Check all that apply.)
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Applied Behavior Analysis (ABA)/Behavior Therapy
Mental Health Counseling
Occupational Therapy
Speech and Langauge Therapy
Other:
Required
In what state(s) do you operate?
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Your answer
What insurances do you accept? (Check all that apply.)
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Aetna
Anthem/BCBS
Cigna
Magellan
Medicaid
Medicare
United/Optum/Oscar/UMR
Other:
Required
What are your hoping to learn or gain from our eligibility and benefits consultation services?
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Your answer
How did you hear about PBT's eligibility and benefits consultation services?
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Your answer
Please share any additional information or questions you may have here.
Your answer
Thank you for taking the time to fill out this form! Someone will reach out to you shortly. If you have any questions or concerns in the interim, please email heather@providencebehaviortherapy.com.
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