ALLIED BEHAVIORAL CONSULTANTS

Medical Record Form

ABC                Allied Behavioral Consultants

314-567-5000  fax 314-567-3110 Golfview Building  

11477 Olde Cabin Road   #200   St Louis MO 63141


Please release my medical records excerpt from Allied Behavioral Consultants to my new provider:



Patient name: _________________________________


Patient birthdate ________________ (MM/DD/YYYY)




New Provider Name: __________________________


New Provider Address: __________________________

_________________________

City_____________________

State__________Zip_______




Enclosed is my check to 'Allied Behavioral Consultants' for handling fee $25.25 plus retrieval fee $23.88 ($49.13 total) as outlined in Missouri Statutes (HB 351)





Patient signature ____________________________Date__________


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