Ryan White | Early Intervention Services Patients Rights and Responsibilities

Please correct the errors described below.

I understand that I am responsible for giving truthful and correct information on this application to the best of my knowledge. Failure to be truthful may prevent or delay determination of eligibility to receive services.

I understand if I knowingly give information that is not true or withhold information and receive services that I am not eligible to receive, I may be lawfully punished and have to reimburse the program.

I understand that the information will be kept confidential in accordance with Florida state law.

I understand that at any time during the application process, I can be denied eligibility if my actions are uncooperative, disruptive of office procedures, threatening, or hostile toward staff.

I understand that PanCare Health cannot discriminate because of race, color, sex, age, disability, religion, nationality, or political beliefs.

I understand I have the right to ask for a meeting with the Program Director if I think my case was unfair or incorrect.

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