The Basics

Please fill out the information below in order for AFC staff to confirm benefit information. 

 

 

Parent Name (when applicable) *
Parent Name (when applicable)
Contact Phone *
Contact Phone
Patient Date of Birth *
Patient Date of Birth
If you do not have a group ID#, please use N/A.
Policy Holder Birthday *
Policy Holder Birthday

CONFIDENTIALITY NOTICE: Please note limits of confidentiality when submitting personal information electronically. When you fill out this form, you will receive a response by email which may include the information provided in your form. Autism Family Center's emails are not encrypted and choosing to communicate via email and other methods of electronic communication may come at a risk for interception. If you are uncomfortable submitting the information electronically, please call Lauren Rabin: 847.814.1096. Thank you!