Ryan White | Consent for Exchange of Information - Early Intervention Services | Consent for Exchange of Confidential Information

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I hereby authorize PanCare of Florida, Inc. (PanCare) Early Intervention Services (EIS) team to exchange with the providers/agencies selected and initialed below records and information pertaining to medical history and lab evaluation, mental, or physical condition, services rendered, or treatment thereof. I understand that this exchange of information necessary to provide comprehensive patient care, coordinate referrals, assessment, services, and care management for me. I understand that the providers/agencies selected below will preserve confidentiality of all patient information and that this consent authorization is valid only for the time period specified below. All or any part of this consent is canceled upon receipt of written notification from the undersigned. Absolutely no information about me or my family will be released to any third party, except my insurance provider, without my written consent, or that of my representative appointed in accordance with state law. I understand that I have the right to receive a copy of this authorization.

Provider / Agency Information Being Released

Initials

BASIC of Northwest Florida

Initials

Family Members

Initials

Health Department

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Other

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Private Medical Provider(s)

This authorization is not limited to the following specific type of information

This authorization is limited to the following specific type of information

Electronic Signature

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EIS Staff Signature

Expiration Date

Your information will be encrypted.