Authorization To Release Information - Pcg Public Partnerships (Page 2 of 2) in pdf

Authorization To Release Information - Pcg Public Partnerships Page 2

III. Client Rights and Acknowledgement

I have read and understood the following statements about my rights:

• I may revoke this authorization at any time by notifying PPC in writing, but the revocation will not

have any effect on any actions the entity took before it received revocation.

• I may see and copy the information described on this form if I ask for it.

• I am not required to sign this form to receive my information. Authorization is not required for PPC to

carry out services, payment and health care options.

• I have the right to seek assurances, from the above named persons authorized to receive the

information, that they will not redisclose the information to any other party without my permission.

__________________________________________ _____________________________

Signature of Client

Date

__________________________________________ _____________________________

Signature of Designated Repersentative

Date

Complete forms should be sent to:

Fax: 1-866-947-4813

Email:

Mail: PO Box 50040 Phoenix, AZ 85076

Authorization to Release Information-Version 2.0, Rev 9-2015

Authorization To Release Information - Pcg Public Partnerships Page 2