Client Consent Withdrawal Form

Client Consent Withdrawal Form

You have the right to withdraw your consent for Paperflower Foundation to communicate with your provider at any time. Please be aware that withdrawing consent may affect the Foundation's ability to continue funding your care. If you have questions before submitting this form please contact us at info@paperflowerfoundation.org.
Client Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
Provider Name*
Full withdrawal of consent — I no longer authorize Paperflower Foundation to communicate with my provider or fund my carePartial withdrawal — I no longer authorize communication with my provider but I have questions about my funding status. Please contact me before taking action.
Effective date of withdrawal

MonthDayYear
Date
Reason (optional):
I understand that withdrawing consent will affect the Foundation's ability to process payments to my provider on my behalf and may result in the suspension or termination of my funding.

I understand that this withdrawal does not affect disclosures already made in good faith prior to the Foundation receiving this form.
Signature*
Date*

MonthDayYear
Date
Should be Empty: