ABA Therapy Referral — Fax Cover Sheet
Arise Autism Center
Fax to: (407) 459-1741 · Phone: (407) 710-8566
- Patient initials
- Patient age
- Parent/guardian name
- Parent/guardian phone
- Insurance
- Diagnosis
- Referring provider
- NPI
- Provider signature
- Date
Please attach
- ABA prescription / order
- Diagnostic evaluation (CDE), if available
- Copy of insurance card (front & back)
Confidential: this fax may contain protected health information intended only for Arise Autism Center.