ABA & Behavioral Therapy for Autism | Connect Plus Therapy

Consent To Release Form

Consent to Release Information - 7/2020

Authorization for use/Disclosure of Protected Health Information

  • Full Name of Parent/ Guardian
  • Name and address of recipient
  • Please name all the PHI's
  • Please choose from one of the following three

  • Please add a specified date if applicable
  • MM slash DD slash YYYY
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