If you do not list a date or event, this permission will last one year from date signed.
By Signing below, I acknowledge that I understand the following:
I can change my mind and cancel this permission at any time. To do so, I need to write a letter to Integrated GIC, and send or bring it to the place where I am now giving permission. If the information has already been given out, I understand that it is too late to change my mind and cancel permission. I do not have to give permission to share my information with the person(s) or organization listed If I choose not to give this permission or if I cancel my permission, I will still be able to receive any treatment and benefits that I am entitled to-, as long as the information is not needed to determine if I am eligible for services or to pay for services that I receive.