Applicant’s Statement:
I understand that this eligibility certification form is a legal document and certifies that the information on this form is true to the best of my knowledge. I acknowledge that such information is subject to verification and that falsification of the form shall be grounds for termination from the program. All such information will be kept confidential. I give permission for myself/my child to receive treatment at the UCHC, and I understand that I may have my prescriptions filled at any pharmacy.