(818) 330-5328

Intake Form

    First Name
    Last Name
    Street Address
    Street Address Line 2
    City
    State/Province
    Postal / Zip Code
    yes, no, not yet, needs updated
    First Name
    Last Name
    Phone Number
    First Name
    Last Name
    Phone Number
    Name of Prescribing Physician
    Phone Number
    Preferred method of contact
    Please provide us with any relevant information that you may feel is important
    name of caregiver with insurance
    #1 Primary Insurance Provider
    OTHER insurance if not listed above
    Group Number primary
    Insurance Phone Number
    please provide name of secondary insurance or NONE
    if applicable we require this information
    2nd Insurance Phone Number

    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.