Welcome to AblePath!

Your First Step Toward Getting Your Child the Support They Deserve

Thank you for choosing AblePath. By completing this short application, you're taking the first real step toward getting your child the personalized, compassionate ABA therapy they need.

This takes about 5 minutes. Once submitted, our team will begin reviewing your information and reach out within 1-2 business days with next steps.

Need help? We're here. Call or text us at (980) 410-5300 or email [email protected]

With warmth, The AblePath Team

Authorization to Use or Disclose Protected Health Information

Pursuant to 45 CFR § 164.508 (HIPAA Privacy Rule)

By signing this Authorization, I certify that I am the parent or legal guardian of the patient and hereby authorize AblePath ABA to use and disclose the following protected health information (PHI):

Information to be disclosed: Clinical records, progress notes, assessment results, treatment plans, diagnostic reports, and insurance-related documentation pertaining to the patient.

Authorized recipients: Primary care physicians, pediatricians, developmental pediatricians, specialists, schools, and insurance carriers (including Medicaid MCOs) involved in the patient's care coordination, insurance authorization, and ongoing treatment.

Purpose: To obtain a physician referral, verify insurance eligibility, support prior authorization, coordinate care with other providers, and facilitate delivery of ABA therapy services.

Expiration: This authorization expires upon the patient's discharge from AblePath ABA services, or upon written revocation, whichever occurs first.

Your Rights

You may revoke this authorization at any time by submitting a written request to AblePath ABA at [email protected] or by fax to 919-913-8918. Revocation does not apply to actions already taken in reliance on this authorization.

Signing this authorization is not a condition of receiving treatment. You may receive services without signing, though doing so may limit our ability to coordinate care and process insurance authorization.

Information disclosed under this authorization may be re-disclosed by the recipient and may no longer be protected under HIPAA.

Signature Date *

Signature of Parent/Legal Guardian: *

Clear

Relationship to Child *

Child's Information

Child First Name *

Child Last Name *

Child Preferred Name

Date Of Birth *

Home Address

City

State

ZIP Code

Child's Gender

Child Primary Language

If Other, please specify language

Contact Information

Primary Guardian

Guardian 1 Full Name *

Relationship to Child

Phone *

Guardian Email *

Secondary Phone Number

Preferred Method of Contact

Phone Call

Text

Best Times to Contact

Morning

Afternoon

Evening

Guardian 2 Full Name

Guardian Relationship to Child

Primary Phone Number

Email Address

Emergency Contact Information

Emergency Contact Name

Emergency Relationship to Child

Emergency Contact Phone Number

If other, please specify