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Testing2018-02-02T15:25:09+00:00

After completing both forms (Patient Information & Release of Information) are completed, please send to our staff by clicking on the SEND buttons below

FULL SPECTRUM BEHAVIOR ANALYSIS, LLC

Patient Information Questionnaire







  • MaleFemale








  • YesNo



INSURANCE INFORMATION: (please make sure to write in all of the information below)If your child has Medicaid, we will need the Medicaid ID number and the GOLD CARD number.




Primary Insurance Information (United Healthcare, Cigna, Aetna, etc.) if no Medicaid coverage







EMERGENCY CONTACT (Parent/Guardian if patient is a minor)





RELEASE OF INFORMATION

:

This authorizes the release or ability to obtain protected health information concerning the above named client.Health information may relate to my past, present or future physical or mental health condition, and the provision of my health
care, or payment for my health care services. This information may be disclosed to or obtained from the following:

MailPhoneFaxEmail

I authorize ALL Health information to be disclosed OR only the following information is/are authorized for disclosure (check all to be released).

Individual Education Plan (IEP)Speech/Language Eval.Client Information SheetPsych Educ. AssessmentHearing ScreeningIndividualized TreatmentReport Cards/TranscriptsMedical HistoryTreatment Plan ReviewsBehavioral ReportImmunization RecordPsychosocial EvaluationSpecial ReportNeurology ReportBehavioral ProgramPsychological EvaluationPsychiatric EvaluationDischarge SummaryMedication Management VisitsProgress NotesProgress Summary

This authorization expires OR

At the request of the IndividualAssessmentTreatment

Disability DeterminationOtherTo obtain information for Brief Behavioral Health Status Exam

Other Information:

  • 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.
  • 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.
  • 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.

A copy of this release shall be valid as the original.
THIS CONSENT EXPIRES I YEAR FROM THE DATE SIGNED UNLESS OTHERWI SE SPECIFIED.

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