ASK - Advocates for Special Kids
"Parents helping parents to understand special education"

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City, State, Zip Code:
Phone #:


Insurance Company:
City, State, Zip Code:

Re: Child Name, Policy #, Group #

To Whom It May Concern:

On ___________  ___, _______, 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. 

In accordance with the findings made by Dr.____________ and others, _________ ‘s program consists of the following types and amount of treatment.

1.                 Type of 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”.

Enclosed please find the following documents:

i.e. Assessments, evaluations, IFSP, IEP’s, etc.

The above 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 progress.

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.



Mother or Father of _____________________.





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Revised: January 25, 2002

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