Provider Referral Form

Welcome to Midwest Autism & Therapy Centers. To submit a referral to one of our locations, please submit the form below. Supporting documentation should be emailed to our secure inbox [email protected] or faxed to (515) 963-5006.

Frequently Asked Questions (FAQs)

What Services Do You Offer?

Midwest provides center-based early intervention ABA therapy for children ages 2-5 and home-based ABA therapy for children ages 5+.

What Insurances Do You Accept?

We accept most major commercial insurances including Aetna, BCBS, Amerigroup, etc. as well as Iowa TotalCare and Medicaid plans.

Where are Home-Based Services Available?

We offer home-based services through our Iowa offices. Our clinicians can travel roughly 25 miles around each of our Iowa locations (Altoona, Ankeny, Waukee, and West Des Moines).

For families who are slightly outside of this range, we review on a case-by-case basis to ensure we have clinicians available.

Do Clients Need to Have A Diagnosis?

To utilize insurance funding, clients do need to have an Autism diagnosis before we can start providing services.

How long Does The Enrollment Process Take?

On average, it takes about 30 days for families to complete the enrollment process and get started with services. The length of the enrollment process may vary depending on how quickly we receive insurance approvals.

Provider Name *

Provider Phone *

Provider Email *

Organization Name

Caregiver's Name(s) *

Caregiver's Phone *

Caregiver's Email Address *

Where is the family located? (Please provide City & State) *

Family's Insurance Carrier *

Please provide only the carrier. DO NOT include any plan information.

Does The Child You Are Referring Have An Autism Diagnosis? *

IMPORTANT: We require a diagnosis before we can begin providing services. We do not currently offer assessments.

Family's Preferred Office *

Family's Preferred Office (2nd Choice)

Family's Preferred Care Setting (1st Choice) *

Child's Name

Child's Age *

Any Notes for Our Care Team?

Please do not provide any sensitive information.

Would You Like to Join Our Provider Mailing List? *

You'll receive first alerts on new locations, services, clinicians, and client openings.

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