Our Team needs more information to check if we can provide ABA Therapy for your children. Please submit the form and we will contact you from 1-2 business days. Thank you.
1) I understand that Full Spectrum Behavior Analysis, LLC cannot guarantee that the Recipient will not re-disclose my health information to a third party. The Recipient may not be subject to federal laws governing privacy of health information. 2) I understand that I may refuse to sign this Authorization and that my refusal to sign will not affect my ability to obtain treatment from Full Spectrum Behavior Analysis, LLC. 3) I understand that I may revoke this Authorization in writing at any time, however, l cannot revoke authorization for action that has already been taken. I further understand that I must provide any notice of revocation in writing to the Business Office at the address listed above.