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I hereby authorize ABA Programming Inc to exchange information from the health records of:
Patient name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Information to be released/ obtained from:
Check all that apply
*
Primary Care Physician
School
Outpatient Specialist
Psychiatrist
Psychologist
Waiver team
Other: (please specify below)
Please list names:
Please list names:
Please list names:
This authorization will remain in effect until such time as it is withdrawn in writing.
Parent Name
*
First Name
Last Name
Parent Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: