Authorization for Release of Confidential Information
Patient Name
First Name
Last Name
Guardian Name (if applicable)
First Name
Last Name
Patient Date of Birth
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January
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Month
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Day
Please select a year
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Year
Email
example@example.com
Type of information to be released:
Assessment(s)
IEP/504
Progress Reports
Treatment Plan
Permanent Record
Diagnoses
Prescribed Medications
Other
I authorize the organization or individual(s) listed below, to release the requested information to Behavioral Learning LLC.
Contact Name
First Name
Last Name
Name of Affiliated Organization
Phone Number of Organization Contact/Individual
Email Address of Organization Contact/Individual
Delivery Method
Please Select
Electronic
Mail - USPS
Address of Organization/Individual
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
For the following purpose:
Continued Medical Care
Legal Purposes
Insurance Purposes
Personal Interest
Other
Consent
I understand that this release is valid from the date it is signed and expires within 1 calendar year from said date. I may withdraw my consent to this release at any time either orally or in writing.
Signature
Submit Form
Should be Empty: