Autism Center Forms
Continue to main contentTo begin working with the University Autism Center, complete an application or referral form.
Forms
Application Form
In this form, you’ll be asked questions about your child’s development and medical history. Our clinical team will review your form and, if appropriate, contact you about making an evaluation or treatment appointment.
Outside Agency Referral
This form is for outside agency use. You’ll be asked about your client’s personal and medical information as well as your reason for referral.
Privacy Practices
This is a summary of the Center's Notice of Privacy Practices and describes how the Autism Center may use and disclose protected health information and how you can access this information. This applies to the clinical programs at the Autism Center.
Good Fath Estimate
You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost. Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.
- You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
- Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
- If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. You may also contact your provider’s office at 537-986-4985.
- Make sure to save a copy or picture of your Good Faith Estimate.
- For questions or more information about your right to a Good Faith Estimate call Toll Free: 877-267-2323, or visit the Centers for Medicare and Medicaid Services website.
Cape Girardeau, MO 63701
Cape Girardeau, MO 63701