Check Eligibility Form *We are currently only accepting medical assistance in Pennsylvania Check Eligibility Form Parent/ Guardian's Name* First Last Email* Phone*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Primary Policy Holder* First Last Birthday of Primary Policy Holder* Date Format: MM slash DD slash YYYY Client Name* First Last Client DOB* Date Format: MM slash DD slash YYYY Client Social Security NumberPatient Diagnoses Code*How did you hear about Connect Plus? We would personally like to thank them.*Upload a copy of the front and back of your insurance card* Drop files here or *We participate with most insurance plans. We are currently only accepting (MA) medical assistance in Pennsylvania.Do you have a Secondary Insurance Policy ?*YesNoUpload a copy of the front and back of your secondary insurance card Drop files here or Connect Plus Location*Please select the closest locationCherry Hill, NJGreater PhiladelphiaFloridaLakewood, NJLos Angeles, CACape May/ Atlantic County, NJDelawareOtherOther Location*I acknowledge that Connect Plus Therapy might not be in-network with my insurance plan and hereby authorize Connect Plus Therapy to check eligibility for ABA benefits:* Parent/ Guardian signature that the above information is true.*