Change HF Program Status

I Would Like to Change or Discontinue my Healthy Futures Services

Mother's Name
Mother's Name
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Please Change Services for the following.

I would like to change services for

Child Information

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I agree to the statement below
By enrolling in Healthy Futures, I authorize the transfer of pertinent information about me and/or my children to healthcare providers and agencies participating in the program, on a need to know basis. I understand and agree that the information transfer can occur by photocopy, electronic file transfer, and/or fax, as the program considers appropriate under the circumstances. I also understand that the program includes data collection for the purpose of population studies and quality control and in no way will I or my children be identified personally in data reporting. I understand that this authorization can be revoked in writing any time after it is signed and my participation in Healthy Futures can be terminated by notifying any member of the Healthy Futures team. I also understand that this authorization will automatically expire at the end of participation in the Healthy Futures program.