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ABA Service Request Form
Once you have completed the following form, please submit accompanying documentation (diagnostic report, referral from a doctor for ABA services or a Medicaid Referral Form - if you have AL Medicaid) by email or fax to:
info@smithgroupbc.com
fax: 334-539-1971
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ABA Service Request Form
Once you have submitted the following form, please download the accompanying intake paperwork, fill out, and return along with the following by email or fax:
Diagnostic paperwork from a medical doctor or psychologist showing diagnosis of Autism Spectrum Disorder within the past three years
Referral for ABA services from a medical doctor or psychologist (or Alabama Medicaid Referral Form if you are insured by Medicaid)
A copy (front and back) of your insurance card
Email:
info@smithgroupbc.com
Fax: 334-539-1971
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