Describe any of the following services your child is receiving or has received in the past: (include where, when, and frequency)
What does the applicant do when he/she is:
I, the parent/guardian of the above named client, hereby authorize Pediatric Complex Care of Arkansas to obtain from any source, any medical or personal information deemed necessary for the care of this client. This is to include written and/or verbal communication in person and over the telephone. I also authorize Pediatric Complex Care of Arkansas to release any medical or personal information to any facility or agency they deem appropriate.