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ONLINE FORMS: HEALTH CARE PROXY AND CONTACT PERMISSION

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I give permission for the individuals listed below to act as the health care proxy for myself or for the minor listed above.
This will allow FCHC to treat the above if they are a minor and/or to discuss my/minor’s care and protected health information (PHI), such as treatment plans, appointments, referrals, etc.

This consent will also allow FCHC to leave messages per your preferred contact method listed below or with the person(s) you have given us permission to communicate with. This may be in regards to appointments, any test results or requests for you to call the center.

I understand that in order to discuss any care with myself or a proxy, I must have a 4-digit PIN on file with FCHC and any persons contacted must provide that information upon request.

This assignment will stay in effect for the duration of my care at FCHC or if a minor, until they turn 18 years of age. I understand that I have the right to amend/change or revoke this assignment of proxy at any time with written notice.