Ehx Consent

Smita Parikh Mengers, MD FAAP & Wendy R. VanBronkhorst, MD FAAP

Please correct the errors described below.

Single Consent to Share Medical Information with Children's IQ Network Providers Treating Me or My Child


As part of our commitment to improve the quality and the coordination of medical care for the children and patients we serve, Smita Parikh Mengers, MD and Wendy R. VanBronkhorst, MD have elected to participate in the Children's National Health System's IQ Network. This innovative program is the first in the country to attempt to provide real-time coordination of care via an electronic medical record that allows an interface between your or your child's health care provider and one of the country's leading children's hospitals.

This SINGLE CONSENT will allow us to share information, for example, with an ER doctor treating you or your child, or with a specialist to whom you have agreed we are to refer you or your child, so that they are able to quickly access critical information about you or your child from your medical record before beginning treatment. This should dramatically reduce the chance of medical errors, including adverse drug interactions or allergic reactions.

Your and your child's healthcare information is encrypted (encoded) and can be accessed only by health care providers who are caring for you or your child and have a need to know.

As Smita Parikh Mengers, MD and Wendy R. VanBronkhorst, MD are a part of the Children's IQ Network, this written SINGLE CONSENT will allow the sharing of information with any provider within the IQ Network whom you have elected to be involved in your or your child's treatment. You do have the option to opt out of the Children's IQ Network. If you choose to opt out, you will need to sign a separate consent form each and every time you or your child need to be seen by another member of the Children's IQ Network other than those at Smita Parikh Mengers, MD and Wendy R. VanBronkhorst, MD.

PATIENT RIGHTS: I have received a copy of the Children's IQ Network (CIQN) Information Sheet. I understand that patient information will still be stored electronically for my provider's records and that an electronic health summary will be available to other providers through the CIQN. I also understand that I have the right to not share (opt-out) health information with other providers within the CIQN.

PROTECTED DISCLOSURE OF INFORMATION: I understand that Children's National complies with all federal and local regulations including the Health Insurance Portability and Accountability Act; and that this Consent includes my agreement that Children's National can use private health information for my treatment or my child's treatment as defined in the Notice of Privacy Practices. I agree to Children's National use of de-identified health information about me or my child for appropriately reviewed and approved research and quality improvement activities.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Your information will be encrypted.