Insurance Verification of Benefits (VOB) Form

Please complete this form to verify insurance benefits for ABA services at Arete Behavioral Solutions.

Client First Name

Client Last Name

Client Date of birth

Gender

Male

Female

Non-binary

Prefer not to say

Previously Received ABA Services?

Yes

No

Is This The Primary Insurance? *

Yes

No

Currently Receiving Other Therapies?

Speech Therapy

Occupational Therapy (OT)

Physical Therapy (PT)

Counseling

Primary Diagnosis

Parent/Guardian Name

Relationship to Client

Primary Phone Number

Email Address

Address

Street Address

City

State

Country

Postal Code

Insurance Company Name

Insurance Phone Number (Member Services)

Policy Holder Name

Policy Holder Date of Birth

Policy Holder Employer (if applicable)

Member ID Number

Group Number

If secondary insurance, please list details

Previous ABA Provider Name

Previous ABA Dates of Service

Upload Insurance Card – Front *

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Upload Insurance Card – Back

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Parent/Guardian Signature *

Clear

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Verify Your Insurance Benefits

Please complete this form so our team can verify your ABA benefits with your insurance carrier.

Insurance Verification of Benefits (VOB) Form