Permission for Treatment, Payment and Operations
I give permission for my child to receive medical, dental, and behavioral health treatment services by First
Choice Health Centers, Inc. I understand that this authorization is valid as long
as my child is enrolled in the school district listed above or until I revoke this authorization
with the Program Coordinator at First Choice. I hereby authorize First Choice to use and disclose my
child's medical/dental information for treatment, payment and healthcare operation purposes. My consent
includes the release of such information to process claims to my insurance company.
I authorize direct payment from my insurance company to First Choice. I also allow disclosure of protected
health information to the school nurse as appropriate. I consent to receiving phone
calls regarding services my child receives or may be eligible to receive. I acknowledge that I have received
a copy of the Notice for Privacy Practices for First Choice Health Centers, Inc., which
further explains how First Choice may use and disclose my child’s Protected Health Information. By signing
this consent form I certify I am the legal guardian and legal custodian of the student named above. I
have read and understand the above and agree with the above paragraph and certify that all the
information provided is true and correct.
To better provide care, the Provider seeks to coordinate integrated delivery through the electronic health
record, which is paperless. The information is shared across provider locations and may be shared
with some other affiliates through a health information exchange.The Provider uses a system that allows
electronic prescribing of medications. I authorize the Provider to request and use my child’s prescription
medication history from other healthcare providers or third party pharmacy benefit payers for treatment
purposes.
By signing this form, I understand and agree that I am allowing the disclosure and access to all my child’s
health information, including information related to alcohol and substance abuse/use, mental
or behavioral health, medication prescription history, and HIV/AIDS. I understand if I do not want my
information stored in the electronic health record (which may be shared through health
information exchanges), and utilized in my care, I will not be able to receive care with from the
Provider, and have the right to opt out of receiving care at any time.
Disclaimer: By signing your name electronically here, you are agreeing that electronic signature is the legal equivalent of your manual signature on this form.
I certify and attest that all of the above information is true and correct. I understand that FCHC may
verify information on this form. I understand that the financial information will determine eligibility
for the center’s sliding fee discount. I also understand that if I intentionally misrepresent my
family’s income, my child will not be eligible to receive services at a discounted rate. I also
understand that I will be financially responsible for all charges incurred should insurance not cover
the services.