Authorization to Release Information

I understand this release is voluntary and applies to all programs and services operated under the supervision of A to Z Behavioral Services, LLC.

I hereby authorize A to Z Behavioral Services, LLC to:

• Exchange, Release and Obtain information from A to Z partner companies.

I hereby authorize this information to be exchanged in the following manner(s):

• Both verbal and written communication

Description of information to be exchanged / released / obtained:

• Education records
• Evaluation/assessment/eligibility records
• Medical records
• Clinical records (including behavior analytic, psychological, physical, occupational, and speech therapies)

This information is to be used for diagnostic, treatment planning and continuity of care purposes only. This release will remain in effect for two (2) years, unless otherwise stipulated or revoked in writing.