Click on button to Download the forms, fill them manually and send through:
Address: 16414 Lake Church Drive, Odessa, FL 33556
Fax: (813) 920 9252
E-mail (scan forms and send to): email@example.com
STEP 2: Obtain a script for “Applied Behavior Analysis Behavior Therapy” from your child’s doctor.
The script must include the child’s full name and birth date, be dated within the last year, and be signed by an MD or DO (no electronic signatures accepted). You can obtain the script directly from the doctor and fax to us at (813) 920-9252 or email to us at firstname.lastname@example.org Alternatively, we can attempt to obtain the script from the child’s doctor, which may result in slightly longer processing times.
Full Spectrum Behavior Analysis and our staff CANNOT move forward in obtaining authorization for your child’s ABA services unless these forms are filled in completely.
On the Release of Information form please make sure to write in the Doctor’s Name, and contact information so we can contact your child’s Doctor to obtain proof of diagnosis.
If you have any questions when completing this form, you may call us at (813) 926 5454