***Please download and save the forms to your computer prior to filling out.
Please email forms to firstname.lastname@example.org or fax to 352.600.3119
If you're interested in being added to our waitlist, please download and complete the case history and patient information form. Email completed forms along with front and back copy of your health insurance card and a copy of the parent's drivers license.
Beginning February 1st, 2017 all children with Medicaid eligibility must obtain prior approval from EQHealth for ABA Therapy (Behavior Analysis Services).
Although the length of time it takes to get full approval for treatment varies with each insurance company,
it generally takes between 10 and 20 business days.
Patient Information Forms
350 Acceptance Way
Clermont, FL 34711
Servicing Lake and Orange Counties