Evaluation Interest Form

Insurance

Oregon Autism Center LLC does not bill insurance directly and Dr. Lundeberg is not an insurance provider. Statement are provided (superbills) that can be submitted by you to your insurance company for reimbursement based on your out-of-network benefits. Please contact your insurance company regarding any out-of-network benefits questions.

Identified Client's Name

Identified Client's Date of Birth

Identified Client's Gender Identify & Pronouns

Person Completing Form (Include Relationship to Proposed Client)

Is the Identified Client Their Own Legal Guardian?

Yes No

If NO, Who is Client's Legal Guardian?

Contact Email Address

Contact Phone Number

Does the identified client have Oregon Health Plan (OHP) insurance coverage? If so, please be aware legal regulations may limit your access to Oregon Autism Evaluations LLC services as Dr. Lundeberg is not an insurance provider.

Yes No

Why are you pursuing an ASD evaluation service and why are you pursuing it now?

What questions are you hoping an ASD evaluation service will answer?

Any other information that you want to share with us regarding your pursing of an evaluation service?

Please indicate what evaluation services you are interested in:

ASD Non-Diagnostic Screening Session

(18+ only)

Comprehensive ASD Evaluation

ASD Evaluation for Therapeutic Recommendations with Verbal Feedback

(21+ only)

Unsure

Note on Evaluation Fees: The ASD Non-Diagnostic Screening Session is a 60-minute appointment. The fee for this service is $435. Both the Comprehensive ASD Evaluation and the ASD Evaluation for Therapeutic Recommendations with Verbal Feedback are billed by the hour at a rate of $290 per hour. In addition to the appointments with client participation (including intake, evaluation sessions, and feedback) other services often needed to complete an evaluation include record review, collateral consultations, consolidation of clinical information, and report writing. By billing by the hour, each client only pays for the services necessary to complete their evaluation. Adolescent Comprehensive ASD Evaluations typically range from $2,500 to $5,000. Adult Comprehensive ASD Evaluations typically range from $4,500 to $6,500. Adult ASD Evaluations for Therapeutic Recommendations with Verbal Feedback (not available for adolescents) typically cost between $2,000 and $4,000. Factors that may impact the overall cost include complexity of the history or diagnostic question as well as the number of differential diagnoses being considered.

Please note, Oregon Autism Evaluations LLC does not bill insurance.

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