*****This section shouldn’t be signed if the above information is completed*****
I, or the child I am parent/guardian to, currently do not have a PCP and understand that it has been recommended that I obtain one. Should I need assistance with this I will be referred to the Physician’s referral program in my area. Once obtained I will notify the clinician and/or coordinator assigned to my case so that the above process can be completed.
*****This section shouldn’t be signed if the above information is completed and we can contact*****
I choose not to have my PCP or any other MD involved with my care be notified of my or my child’s involvement in mental health and/or psychiatric services. I understand that should I be prescribed medication or there be a significant event that warrants medical consultation this issue will again be discussed with me.