MDA Release FormMDA Release Form

 I , give Augmentative Communication Consultants, Inc. permission to contact and discuss third party funding issues with MDA (Muscular Dystrophy Association) on my behalf.

 Signature of Client

DATE:

If Client is unable to sign:

Sign Client full name:

Representative Signature:

Relationship to client:     Representative Name: 

 Representative Address: 

City:       State:      Zipcode: 

Reason client unable to sign:      Date: 

Original signature and date are required by Medicare.  Please mail back to:

Augmentative Communication Consultants, Inc.

P. O. Box 731

Moon Township, PA  15108  

Business:  412 264-6121

Fax:           412 269-0923