REVOKE OF PARENTAL PREAUTHORIZATION FOR MEDICAL CARE TO CHILDREN

UNITED COMMUNITY HEALTH CENTER - MARIA AUXILIADORA, INC.
REVOKE OF PARENTAL PREAUTHORIZATION FOR MEDICAL CARE TO CHILDREN
I (we) request to revoke Parental Preauthorization with United Community Health Center and its personnel for the medical care to my (our) child listed below:
Patient Name*

First NameLast Name
Date of birth*

MonthDayYear
Date
By signing, you agree your electronic signature is the legal equivalent of your manual/handwritten signature. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing.
Signature (must be VALID LEGAL NAME or this form will be invalid)*

First NameLast Name
Printed name*
Relationship to Patient*
Date*

MonthDayYear
Date
NOTE: If any special parental or custodial relationship (such as custody with one parent only, legal custody/guardians with no parent, etc is in place, please explain in the space below.
LEGAL DOCUMENTATION MUST BE PROVIDED (please briefly explain if special parental or custodial orders).
At any time, you want to authorize such treatment in advance, a new Preauthorization Form must be completed.
Should be Empty: