EMIT Therapeutics Service Enrollment Form

If you’re ready to enroll your child with EMIT Therapeutics, fill out our convenient intake form today. If you have any questions or concerns, contact us today by calling 908.376.6278.

Enrollment Form

Family Information
Child Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Gender
- Male
- Female
Does student have a medical ASD diagnosis?
Responsible Caregiver Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email
Name of Prescribing Physician
Hours available for ABA services (*10 hour minimum required)
- Morning
- Afternoon (11-3)
- 4pm - 7pm
- After 7pm
- Weekend Flexable
- Other
If Other, Specify:
Days Requesting Services (*4 days a week required)
- Monday
- Tuseday
- Wednesday
- Thursday
- Friday
- Saturday
- Sunday
Referred by:
First Last
Comments
Parent(s)/Legal Guardian Information
Name
First Last
Phone
Email
Insurance Information
Policyholder Name:*
First Last
Policyholder Social Security Number*
Primary Insurance Provider*
If Other, Specify:
Relationship to Patient
- Mother
- Father
- Self
- Other
If Other, Specify:
Insurance ID*
Group Number*
Insurance Contact Number*
Snap or upload photo of front of insurance card
Accepted file types: jpg, jpeg, png, gif.
Snap or upload photo of back of insurance card
Accepted file types: jpg, jpeg, png, gif.
Thank you for your application someone will contact you within 24 hours.

IMPORTANT: Before we can verify your coverage with your insurance company, we need a copy of the front and back of your insurance card. Please scan or snap a picture of both sides and submit them here or email support@ascendautism.com. If you require assistance, please call us at 877-323-8668 or email us.

A quote of benefits and/or authorization does not guarantee payment. Payment of benefits is subject to all terms, conditions, limitations, and exclusions of the member’s contract at the time of service. *** You will always be solely responsible for letting your provider know about any changes in insurance and or payment status for services. Any services not fully covered by insurance will be the responsibility of the patient/family.
Consent*
This selection signifies a signature.

Enrollment Form

Family Information

Parent(s)/Legal Guardian Information

Insurance Information

DO YOU HAVE QUESTIONS?

GET IN TOUCH WITH US TODAY!

Get the Individualized Autism Care
Your Child Needs

Service Enrollment Form

Enrollment Form

Family Information

Parent(s)/Legal Guardian Information

Insurance Information

DO YOU HAVE QUESTIONS?

GET IN TOUCH WITH US TODAY!

Get the Individualized Autism Care Your Child Needs

Get the Individualized Autism Care
Your Child Needs