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Insurance Intake Form
Insurance Intake Form
  1. If you would like to find out if your health insurance covers ABA please complete STE's Secure Intake Form. Once you have electronically submitted your information we will contact you within 48-hours.
  2. Disclaimer: STE can not guarantee ABA coverage by any health plan.
  3. Parent or Guardian*
    Please type your full name.
  4. Email*
    Please let us know your email address.
  5. Phone Number*
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  6. How should we contact you?
  7. Patient Name*
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  8. Client Status*
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  9. Date Of Birth*
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  10. Age
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  11. Address*
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  12. City*
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  13. State*
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  14. Zip*
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  15. Member ID*
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  16. Insurance Co*
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  17. Other Insurance
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  18. Phone Number
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  19. Prescribing Doctor
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  20. Diagnosis*
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  21. Other Diagnosis
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  22. Additional Information
    Please let us know your message.
  23.  
  1. Authorization for Exchange and Release of Information I hereby give permission to (NAME and address of agency RELEASING INFORMATION):
  2. Name and Agency*
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  3. Address*
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  4. City*
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  5. State*
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  6. Zip*
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  7. To release the following information in my medical record. This information may be released as photocopies and/or verbal exchange. Check specific records to be released:
  8. Medical Record Release*




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  9. Release Other
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  10. Additionally I authorize the release of:
  11. Additional Release




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  12. The Information may be release to: STE Consultants, LLC 2560 9th Street, Suite 219 Berkeley, CA 94710
  13. For the Purpose of continuity of care or
  14. (list other)
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  15. I hereby release the facility releasing the information from any liability that may arise from the use of the information contained in the records released. I understand that:
  16. • I may request a listing of all records released. • I have a right to see my record and request an amendment to my record. • STE Consultants, as the sending agency, cannot guarantee that the Receiving agency will not re-disclose my information to a third party. • STE Consultants, as the Receiving agency, will maintain any received information under strict guidelines for the maintenance of confidentiality. • If any information in my record is protected by the Federal Substance Abuse Confidentiality Regulation, the recipient may not re-disclose such information without my further authorization. • This authorization expires one year from the date on which it was signed. • I may revoke this authorization in writing at any time except that the revocation will not have any effect on any action taken by the Provider based on this Authorization prior to revocation.
  17. Client Name*
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  18. Today's Date*

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  19. Signature of client or legal guardian*
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  20. To Receiving Agency: Prohibition on re-disclosure. This information has been disclosed to you from records whose confidentiality is protected by law. This law prohibits you from making any further disclosure of this information without specific written consent of the person to whom such information pertains. This authorization is not sufficient for this purpose.
  21. Please upload a copy of the front and back or your insurance card.
  22. Front of Card:
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  23. Back of Card
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  24. How did you hear about us?
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  25. Invalid Input
  26.   
  27. If you have any problems with our online form you may download it as a PDF by going to http://www.steconsultants.com/b/images/stories/STE_EVR.pdf. Fax it to 510-665-9400 or scan and email it to intake@steconsultants.com.

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24.05.2013
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