City, State, Zip Code:
City, State, Zip Code:
Name, Policy #, Group #
To Whom It
___________ ___, _______, my child,
___________________, was evaluated and diagnosed by _____________ with Autism,
speech delays, motor delays, communication delays, daily living skills delays,
socialization delays, developmental delays, sensory issues and other concerns.
accordance with the findings made by Dr.____________ and others, _________ ‘s
program consists of the following types and amount of treatment.
treatment. Hours per week.
Name of treatment provider. Address
and phone # of treatment provider.
All of the
above mentioned providers for _________ are vendors with Harbor Regional Center,
the local State Agency, and are fully licensed in their respective fields.
I am hereby requesting that _________ assume financial responsibility for
___________ entire treatment program immediately under our health care plan and
pursuant to AB88, Health and Safety Code Section 137.72.
This Code Section provides that “(a) every health care service plan
contract issued, amended or renewed on or after July 1, 2000, that provides
hospital, medical, or surgical coverage for the diagnosis and medically
necessary treatment of severe mental illnesses of a persona of any age and of
serious emotional disturbances or a child, as specified in subdivisions (D) (E),
under the same terms and conditions applied to other medical conditions, as
specified in subdivision (C) .......(C) the terms and conditions applied to the
benefits required by this section, that shall be applied equally to all benefits
under the plan contract, shall include, but not be limited to, the
following........(7) Pervasive developmental disorder or autism”.
please find the following documents:
Assessments, evaluations, IFSP, IEP’s, etc.
outlined therapies have been deemed medically necessary. The failure to provide the prescribed course of treatment to
__________ now will delay his optimal recovery particularly since he falls
within the young, preschool age group which has been proven to receive maximum
benefit from early intervention. Furthermore,
the failure to immediately authorize the above treatment plan will injure the
future expected recovery and would permanently impact ______’s long term
If you have
any questions or need further information, please do not hesitate to contact me
at __________. Due to the time
sensitive nature of this request, I would appreciate an immediate response.
or Father of _____________________.