Pediatric History Form (Page 5 of 5) in pdf

RIGHT TO REVOKE AUTHORIZATION:

You have the right to revoke this AUTHORIZATION, in writing, at any time. However, your written

request to revoke this AUTHORIZATION is not effective to the extent that we have provided services

or taken action in reliance on your authorization.

You may revoke this AUTHORIZATION by mailing or hand delivering a written notice to the Privacy

Official of FFC. The written notice must contain the following information:

Your name, Social Security number and date of birth;

A clear statement of your intent to revoke this AUTHORIZATION;

The date of your request and

Your signature.

The revocation is not effective until it is received by the Privacy Official.

This AUTHORIZATION is requested by FFC for its own use/disclosure of PHI.(Minimum necessary

standards apply.)

I have the right to refuse to sign this AUTHORIZATION. If I refuse to sign this AUTHORIZATION, FFC

will not refuse to provide treatment however, it will not be possible for FFC to file third party billing on

my behalf and I will be responsible for 1) payment in full at the time services are provided to me 2)

scheduling my own appointments since FFC will be unable to contact me 3) all contact with FFC

regarding my care. Additionally, any collection activity as permitted by law is not waived by refusal to

sign the authorization.

I have the right to inspect or copy, within boundaries the protected health information to be

used/disclosed A reasonable fee for copying will apply. A copy of the signed authorization will be

provided to me.

HEALTHCARE AUTHORIZATION

I have read and understand this Healthcare Authorization form and acknowledge receipt of the Notice

of Privacy Practices for Protected Health Information. My signature below represents agreement with

these practices.

SSN:_____________________________DOB:__________________________

My name (please print):____________________________________

My Signature: _________________________________

Today's Date: ________________________________

Name of personal Representative (if someone is designated to act on your behalf)

Name (please print): _____________________________

Signature of Personal Representative: ______________________________

Description of Representative's Authority to Act on Patient's Behalf: ____________________

__________________________________________________________________________

Pediatric History Form Page 5