South East Early Intervention Program - EI435.381.2667[email protected]15 East 600 North Suite BCastle Dale, Utah 84513
Weeks Premature (put "0" if not premature)
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If I choose not to submit this and share my child’s screening data as stated above, I may request a paper screening option from my child’s provider.
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I understand that I may revoke this authorization at any time and the revocation does not apply to any action that has taken place prior to the date I revoke this authorization.
To revoke this authorization, I must make a request in writing and send it to: [email protected].
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