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Ty Act (HIPPA), August 21, 1996. This form will not be used for authorization to disclose psychotherapy notes, alcohol or drug abuse patient information from medical records or for authorization to disclose information from records of an alcohol or drug abuse treatment program. I authorize Educational and Developmental Intervention Services (EDIS) to release the requested evaluation information identified on the Parent Permission for Evaluation (page one of this form) to the Case Study Commit.

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