CALL US: 781.354.4500 | EMAIL US: info@specializedautism.com

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ABA Enrollment Application

Please complete the enrollment application as completely as possible and submit along with a photo of the front and back of your insurance card. If you’d prefer to submit your information offline, you can give us a call at 781-354-4500. See below for insurance information.

Policyholder Information

Name

Date of Birth

Address

City

State

Zip

Phone

Email

Child Availability

Sunday:

Monday:

Tuesday:

Wednesday:

Thursday:

Friday:

Saturday:

Child Information

Name

Date of Birth

Diagnosis

Primary Insurance Information

Insurance Company

Member ID

Group ID

Please upload a photo of the front & back of your insurance card

Insurance

Specialized Autism Consultants will support you in determining if you have insurance benefits for ABA and, if so, in accessing those benefits, including dealing with authorizations and billing.

We're currently in-network with the following insurance companies:

  • MassHealth
  • Aetna
  • Beacon Health Strategies
  • Blue Cross Blue Shield
  • Harvard Pilgrim
  • Triwest
  • United Behavioral Health