REVOKE OF PARENTAL PREAUTHORIZATION FOR MEDICAL AND/OR BEHAVIORAL HEATH CARE TO CHILDREN

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

First NameLast Name
Date of birth*

MonthDayYear
Date
Parent/Guardian Signature*

First NameLast 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
At any time, you want to authorize such treatment in advance, a new Preauthorization Form must be completed.
Should be Empty: