Under 18 Release of Information Form

By signing below, I hereby authorize, in addition to the legal guardians of the patient, the adult persons listed below may schedule and/or accompany the patient(s) listed above to their appointments, receive any and all protected health information about the patient and consent to the provision of medical care for the patient including, but not limited to: providing a history of present illness, any and all healthcare examinations, diagnostic testing, administration of immunizations, and any other medical treatment deemed reasonably medically necessary by Bloomington Pediatrics. This consent will expire upon the patient’s 18th birthday, at which time a new consent must be signed by the patient.

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.

Before the patient’s 18th birthday, the above authorization may be revoked or updated by notifying the practice either in person or in writing and a new authorization may be submitted. In situations of parental separation or divorce, legal documentation must be provided to validate single parent authority on medical decision making, or that a parent does not have legal access to the patient record or to make such changes. No action will be taken without court documentation to support the request.