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.*Where are you looking to receive services? Center Home Summer Camp Private School/ Day Care Other Upload a copy of the front and back of your insurance card* Drop files here or *We participate with most private insurance plans. 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*Cherry Hill, NJGreater PhiladelphiaLakewoodDelawareFloridaOtherI 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.*