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<br />CalOptima Health PHA MOU Page 17 of 18 <br />Consent Form is effective on the date provid ed below. Unless otherwise revoked earlier in writing, <br />this authorization expires five (5) years after the date you sign. <br /> <br />I understand that I may terminate this Voluntary Consent Form at any time by submitting a <br />written notice to the Housing Authority. Termination of this Voluntary Consent Form will not <br />apply to information that was shared under this Voluntary Consent Form prior to its termination. <br />I confirm that I have read the preceding information, agree to its contents, and have re ceived a <br />copy of this form. I also understand that signing this form is voluntary and that I am not required <br />to sign this form. Treatment, payment, or eligibility for benefits provided by the Housing <br />Authority, CalOptima, and CalOptima’s contracted Medi -Cal providers will not be affected if I do <br />not sign this form. Any questions that I may have had have been answered fully and to my <br />satisfaction. I am the individual indicated below, the individual’s legal representative, or am <br />otherwise authorized by the individual to sign the below and accept these terms on their behalf. If <br />I am not the individual, I understand and agree that any references to “I”, “you”, or “my” are <br />deemed to include the individual. <br /> <br /> <br />Head of Household or Legal Representative (Print Full Legal Name) Signature Date <br /> <br />Home Address City State Zip Code <br /> <br />Email Address Date of Birth Telephone number <br /> <br /> <br />Co -Head/Other Adult or Legal Representative (Print Full Legal Name) <br /> <br />Signature Date <br /> <br /> <br />Email Address Date of Birth Telephone number <br /> <br />Other Adult or Legal Representative (Print Full Legal Name) <br /> <br />Signature Date <br /> <br /> <br />Email Address Date of Birth Telephone number <br /> <br />EXHIBIT 1