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The Public Health Programs listed below will use this data: 1.) To determine whether I am eligible to participate in those programs; and/or 2.) To provide services under those programs if I am eligible and wish to participate. 3.) If referred, my medical provider will use the data to provide health care to me.
I give my consent to the Chisago County WIC (Women & Children) Program to release and exchange information about myself and/or my minor child(ren) with:
WIC Program data about you is private and is protected by federal and state privacy law. The Chisago County WIC Program will not release identifying data to any person without your permission.
I understand that I do not have to agree to the release of information described in this document. I also understand that refusing to sign this authorization will not affect my eligibility or participation in the WIC Program or any other Public Health Program, will not affect the current or future care I receive from any health care provider, and will not cause any penalty or loss of benefits to which I am otherwise eligible.
I may cancel my permission at any time. In order to cancel my permission, I need to provide notice in writing to the Chisago County WIC Program and include my name, date of birth and signature.
This field is not part of the form submission.
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