Becoming a LAF Family is easy. Simply complete the contact and release form below and hit “submit”. After completing the contact and release forms, families will have access to all LAF programs and services.

Family Form:

Child's Name

First Name

Last Name

Child's Date of Birth

YYYY

Guardian's Name

First Name

Last Name

Phone Number

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

County

Primary Diagnosis

Other Diagnoses

Ethnicity (optional)

Primary Insurance

Secondary Insurance

Release of Information

Lowcountry Autism Foundation (LAF) has permission to Request and/or Release information contained in the Medical Record of the above named patient and may provide and/or request information from the following parties:

Pediatrician or Primary Care Physician

Please list the practice and physician name

School

Please list name and address of school

BabyNet

If your child is enrolled with BabyNet, please list the name of your provider.

DDSN

Please list the name of your child's case manager with Department of Disabilities and Special Needs

DHHS

Please list the name of your child's case manager with Department of Health and Human Services

Other

Please list any other therapists or providers.

Authorization

I hereby authorize LAF to release any medical information as requested above. This may include information about care/treatment received by my child at LAF. I understand that information used or disclosed under this authorization may be subject to re-disclosure by the recipient without being further protected under the HIPAA rules. I am aware that LAF cannot control how the recipient uses/shares the information, and that laws protecting its confidentiality at LAF may or may not protect this information once it has been disclosed to the recipient. I understand that LAF will continue to provide care, even if I do not authorize this release.

Electronic Signature

By entering your first and last name, you are signing this release of information form electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this release of information form. By entering your first and last name using any device, means or action, you consent to the legally binding terms and conditions of this release of information form. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting agreement between you and Lowcountry Autism Foundation, Inc. You are also confirming that you are the guardian authorized to enter into this release of information for the above listed minor.

First Name

Last Name

Click here for Provider Referral Form

Family Form:

PHONE: 843-800-7171