Life Skills Autism Academy is committed to a culture of transparency

Clients are offered access to their Electronic Health Information (EHI) through our request system below in a format of their choosing. Should you not have the information necessary to complete the form please consult with your treatment team (Supervising Clinician or Field Staff Manager/Operations Director).

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Client Name

Requestor Name

Date of Request

Date of Birth

Client Address

Request

The entire medical record (all information)

Service Notes(Technician/Care Attendant)

Billing Information

Physician/Medication Records

Clinical Progress Notes

Admission/Discharge Records

Clinical Assessments

Professional Conusltation Notes

Other(Describe as specifically as possible)

I request access to my health information as indicated above covering the dates

From Date

To Date

Type of Access Requested

Format Requested

Paper Records

PDF

Other

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Note: All documentation will be sent to the contact information we have on file. Please allow 10 Business Days for delivery. If you encounter difficulties in completing this form please contact your treatment team for assistance.

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Toll-Free Phone Number: call-Life Skills Autism Academy(888) 975-4557Click to call on Toll Free Number (888) 975-4557

email-Life Skills Autism Academyinfo@lifeskillsautism.com

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