Form Oci 26-501 - Uniform Employee Application Page 9
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9_______________________
Employee Name
V. Right to Revoke
I understand I, my spouse or my dependent child(ren) may revoke this authorization at any time by giving advance written notice to Insurers.
Revocation of this authorization form will not affect actions Insurers and others took in reliance on this form prior to the written notice of revocation.
I HAVE HAD FULL OPPORTUNITY TO READ AND CONSIDER THIS FORM. I UNDERSTAND THAT, BY SIGNING THIS FORM, I AUTHORIZE
THE USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION DESCRIBED IN THIS FORM. I UNDERSTAND THAT I MAY ONLY
REVOKE AUTHORIZATION FOR MYSELF OR MY MINOR CHILD(REN) UNLESS MY MINOR CHILD(REN) HAS RECEIVED TREATMENT
WITHOUT MY CONSENT, CONSISTENT WITH STATE LAW. (CONTINUED ON THE NEXT PAGE.)
_______________________________________
_____________________
_________________________________
Signature of Adult Applicant
Date signed
Printed Name
_______________________________________
_____________________
_________________________________
Signature of Spouse (if applicable)
Date signed
Printed Name
AUTHORIZATION TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION (Continued)
I HAVE HAD FULL OPPORTUNITY TO READ AND CONSIDER THIS FORM. I UNDERSTAND THAT, BY SIGNING THIS FORM, I AUTHORIZE
THE USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION DESCRIBED IN THIS FORM. I UNDERSTAND THAT I MAY ONLY
REVOKE AUTHORIZATION FOR MYSELF OR MY MINOR CHILD(REN) UNLESS MY MINOR CHILD(REN) HAS RECEIVED TREATMENT
WITHOUT MY CONSENT, CONSISTENT WITH STATE LAW.
_______________________________________
_____________________
_________________________________
Signature of Adult Dependent
Date signed
Printed Name
(if applicable)
_______________________________________
_____________________
_________________________________
Signature of Parent or Legal Guardian
Date signed
Name of Minor Child (please print)
for Minor Child(ren) (if applicable)
If signing for more than one child, please list the names of each child for whom you are signing:
_________________________________________
_________________________________________
Name of Minor Child (please print)
Name of Minor Child (please print)
_________________________________________
_________________________________________
Name of Minor Child (please print)
Name of Minor Child (please print)
For services received by a minor that under state law the minor may consent to treatment without parental or legal guardian consent:
_______________________________________
_____________________
_________________________________
Signature of Parent or Legal Guardian
Date signed
Name of Minor Child (please print)
for Minor Child (if minor received
treatment with knowledge of parent)
_______________________________________
_____________________
_________________________________
Signature of Minor Child (if minor may have
Date signed
Name of Minor Child (please print)
received treatment that does not require
parent or legal guardian authorization)
_______________________________________
_____________________
_________________________________
Signature of Minor Child (if minor may have
Date signed
Name of Minor Child (please print)
received treatment that does not require
parent or legal guardian authorization)
Uniform Employee Application
Page 9 of 9
OCI 26-501 (R 6/2010)
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