(818) 330-5328

Intake Form

    First Name

    Last Name

    yes, no, not yet, needs updated

    First Name

    Last Name

    Phone Number

    Preferred method of contact(E-mail or Phone)

    Please provide us with any relevant information that you may feel is important

    #1 Primary Insurance Provider

    if applicable we require this information

    OTHER insurance if not listed above

    Thank you for your application we will contact you within the next 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 info@ahappyfam.com If you require assistance, please call us at 818-330-5328 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 changes in insurance and/or payment status of services. Any services not fully. covered by insurance will be the responsibility of the patient/ family, caregiver

    Privacy Disclaimer A Happy Family will never sell your information to any third-party person we are committed to protecting your personal information and your right to privacy, please contact us at info@ahappyfam.com if you have any questions

    Privacy guarantee: We do not share your information and will contact you only as needed to provide our ABA service.