Take a Tour

To set up a tour of one of the centers, please send an email to the family coordinator, Colin Clayton, at cclayton@thebaca.com or call 317-436-8961.

Funding

The BACA will help navigate and attain all information to secure the best funding for you. We offer in house billing and an accounting department with customized billing software and easy to read statements. Our knowledgeable team is ready to meet you or pick up the phone to answer any questions and provide clear direction.
Please fill out the section below to determine current coverage.

Client Information

Today's Date*
LAST NAME*
FIRST NAME*
DOB*
GENDER*
- M
- F
STREET ADDRESS*
CITY*
STATE*
ZIP CODE*
DIAGNOSIS:*
DIAGNOSING PHYSICAN:*
DIAGNOSIS DATE:
FINANCIALLY RESPONSIBLE PARTY
LAST NAME*
FIRST NAME*
DOB*
GENDER*
- M
- F
STREET ADDRESS*
CITY*
STATE*
ZIP CODE*
HOME TELEPHONE*
WORK TELEPHONE
EXT
CELL PHONE*
PRIMARY INSURANCE
Insurance Co.*
Subscriber Name*
Subscriber DOB*
Insurance Address*
Ins. PH No.*
EMPLOYER*
ID#*
GROUP*
SECONDARY INSURANCE
Insurance Co.*
Subscriber Name*
Subscriber DOB*
Insurance Address*
Insurance PH No.*
EMPLOYER*
ID#*
GROUP#*
Please list any other health insurance policy information.
AUTHORIZATION AND RELEASE
Instructions
I authorize BACA to release any or all medical records or information necessary to process medical claims. I authorize a copy of this authorization to be used in place of the original & request payment of benefits either to myself, or the above provider who acquires assignment. I acknowledge that I remain financially responsible for unpaid co-insurance and deductible balances & amounts not covered by commercial third party payers.
SIGNATURE of RESPONSIBLE PARTY*
Date
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Funding

Client Information