Change Program Status – Healthy Futures

I Would Like to Change or Discontinue my Healthy Futures Services

Mother's Name

First

Last

Mothers Birth Date

Home Phone

Cell Phone

Alternate Phone

Email

Ok to leave message?

Yes

No

Can we text you?

Yes

No

Please Change Services for the following.

I would like to change services for

All Enrolled Children/Pregnancies

Current Pregnancy Only

Selected Children Only

Child Information

Child's Full Name

Date of Birth

Add Remove

Please Choose Level of Service.

Would you still like to receive contacts from your Healthy Futures Nurse?

Yes

No

Would you still like to receive Newsletters?

Yes

No

Would you still like to receive Texts?

Yes

No

Notes

I agree to the statement below

I agree

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.