County New Patient Notification HiddenPhone*Do not edit. Pre-filled for your convenience.HiddenEmail*Do not edit. Pre-filled for your convenience. Clinic Name* Patient Name* First Last Sex* Male Female Patient Date of Birth* MM slash DD slash YYYY Patient Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Diagnosis*Choose OneF84.0 Autistic DisorderQ99.2 Fragile X SyndromeQ90.0 Trisomy 21, nonmosaicism (down syndrome)F84.9 Pervasive Developmental Disorder, unspecified (PDDNOS)OtherOther Important! You will need to upload the County Authorization Form below.Upload the County Authorization Form Drop files here or Select files Max. file size: 256 MB. Δ
