Please list Emergency Contacts other than the Parent/Guardian.

As the parent or authorized representative, I hereby give consent to Montessori Autism Programs and Services to obtain all emergency medical or dental care prescribed by a duly licensed physician (M.D./D.O.) for my child. This care may be given under whatever conditions are necessary to preserve the life, limb, or well being of my child.

Please list individuals that are authorized to pick up the patient from MAPS programs.

I understand that the information used or disclosed pursuant to this authorization may be subject to redisclosure and no longer be protected under federal law. However, I also understand that federal or state law may restrict redisclosure of drug/alcohol diagnosis, treatment or referral information, mental health information and genetic testing information. Refusal to sign the authorization will not adversely affect your ability to receive health care services or reimbursement for services. The only circumstance when refusal to sign means you will not receive healthcare service is if the health care services are solely for the purpose of providing health information to someone else and the authorization is necessary to make that disclosure. You may revoke this authorization in writing at anytime. If you revoke your authorization, the information described above may no longer be used or disclosed for the purposes described in this authorization. Any use or disclosure already made with your permission cannot be undone. To revoke this authorization, please send a written statement to MAPS, Intake Department at 1106 Windfield Way El Dorado Hills, Ca 95762 and state that you are revoking this authorization. To revoke this authorization orally, please contact MAPS Intake Department at (916) 357-5837 and state that you are orally revoking this authorization. By signing below, I acknowledge that I have read and understood this authorization. Unless revoked, this authorization expires in 12 months.