RAINBOW PEDIATRICS GENERAL CONSENT FORM

Please correct the errors described below.

Medical Information

By initially here I am agreeing that the person listed below may have access to my children(s) medical records, scheduling and canceling of appointments, viewing treatments, prescriptions and lab results. your provider at Rainbow Pediatrics, may request and use your prescription medication history from other healthcare providers and/or third-party pharmacy benefit payers for treatment purposes.

Permission to Evaluate Minor Child

By initially here I am agreeing that the person listed below may bring my child to his/her appointments. Should any medical decisions need to be made, the parent will be contacted prior to any action being taken and if consent is given, a Rainbow Pediatrics associate must be on the phone to acknowledge such permission has been granted. your provider at Rainbow Pediatrics, may request and use your prescription medication history from other healthcare providers and/or third-party pharmacy benefit payers for treatment purposes.

ePrescribe Program

By initially here I am agreeing that your provider at Rainbow Pediatrics, may request and use your prescription medication history from other healthcare providers and/or third-party pharmacy benefit payers for treatment purposes.

Fax

By initially here I am agreeing that Rainbow Pediatrics has my permission to fax forms regarding my child to his/her school or daycare provider.

NOTICE OF PRIVACY PRACTICES

By initially here I am agreeing that Rainbow Pediatrics provided me with a written copy of their Notice of Privacy Practices. I also acknowledge that I have been afforded the opportunity to read the Notice of Privacy Practices and ask questions.

By signing below, I acknowledge that I have read, understand and agree to abide by the statements contained in this document for the above listed patient.

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

Your information will be encrypted.

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