***Include a copy of the insurance card (front & back), and a copy of the diagnostic evaluation***

Behaviors of concern: i.e., hitting, biting, screaming, running away, throwing etc. & frequency:

HIPAA Release of information AUTHORIZATION FORM

minor child to HOWARD INTERVENTION CENTER, INC. for the purpose of obtaining ABA therapy services and health benefit coverage issues. I understand that any personal health information or other information released to the person or organization identified above may be subject to re-disclosure by such person/organization and may no longer be protected by applicable federal and state privacy laws. This authorization is valid from the date of my/my representative’s signature to the date my services end with HOWARD INTERVENTION CENTER, INC

I understand that I have a right to revoke this authorization by providing written notice to HOWARD INTERVENTION CENTER, INC. I also understand that I have a right to have a copy of this authorization. I further understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect my eligibility for services.

Legal Representatives sign below: By signing this form, I represent that I am the legal parent/guardian of the minor child identified above and will provide written proof that I am legally authorized to act on the minor’s behalf with respect to this authorization form.