County New Patient Notification Phone*Do not edit. Pre-filled for your convenience.Email*Do not edit. Pre-filled for your convenience. Clinic Name*Patient Name* First Last Sex*MaleFemalePatient Date of Birth* MM DD 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)OtherOtherImportant! You will need to upload the County Authorization Form below.Upload the County Authorization Form Drop files here or
