insurance required documents

Please download and print each documents in color. If you have questions regarding what forms to complete, please contact our office at (916) 364-7800.

Form 1500

Consent for Medically Necessary ABA Treatment

Member Responsibility Agreement Form

Consent to Exchange Information

Credit Card Authorization Form

Release of Information

Coordination of Benefits (Cigna clients only)

Authorization to Disclose Protected Health Information to PCP (Magellan clients only)

Please mail in the completed forms to:

4540 Harlin Drive

Sacramento CA 95826