Refer a Patient | Spectrum Optimal Care, LLC

Secure Patient Referral

Hello fellow providers and professionals. Please use this HIPAA compliant intake form to refer clients who would benefit from Parent-Led ABA Services.

We have a few guidelines, based on the insurers we work with:

Only ages 2-21 are typically covered through insurance.
Formal Autism diagnosis is required by most insurances
Find a list of insurances we are currently in-network with here.

Our intake coordinator will reach out to the family within 48 business hours of this submission. Typically, families can expect to have a scheduled initial assessment within 1-3 weeks of us receiving a referral.

Process Transparency

Referral received -> Insurance Auth Verified -> FBA Scheduled with family

Referring Provider Information

Provider Name & Title

Contact Email

Contact Person and Title (if different)

Secure Fax Number

Practice / Clinic Name

Provider Phone Number

Ext

Patient Information

Patient Full Name

Patient DOB

Month

Day

Year

Primary Diagnosis (ICD-10 Code if known)

Gender

Address

Parent / Legal Guardian Information

Full Name

Relation to Patient

Primary Phone Number

Primary Language Spoken at Home

Address if different than patient

Insurance Information

Primary Insurance Provider

Policy Holder Name

Member ID / Policy Number

Group Number

Any additional details or notes you would like to add.

Please upload any supporting documentation to expedite the intake and insurance authorization process.

ASD Diagnostic Report

Script for ABA

Insurance (Front & Back)

I attest that I am a licensed healthcare provider (or acting on behalf of one) and have obtained the necessary consent from the patient's legal guardian to securely transfer this Protected Health Information (PHI) for continuity of care.

Digital Signature

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Today's Date

Month

Day

Year

What happens next?

Confirmation: You will receive an automated notification that your submission was received successfully by our secure server. We will review your referral packet within 24 business hours.
Verification: Our dedicated intake team will review the documentation and immediately run a preliminary insurance benefits verification.
Family Outreach: We will contact the family directly within 48 business hours to discuss the intake process and coordinate the initial FBA.

SpectrumOptimalCare@gmail.com

(442) 205-6463

Secure Patient Referral

Spectrum Optimal Care Helping families meet
their maximum potential.