Permission to Authorize Medical Care of a Minor

Wonder Kids Specialty Pediatrics

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I, the undersigned parent or legal guardian does hereby give the following individual(s)

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Permission to authorize Wonder Kids Specialty Pediatrics to provide routine or emergency medical care as they deem necessary on my behalf for my minor child, and in doing so to obtain confidential information under HIPAA laws regarding my child’s medical records, treatment, and diagnosis.

I, (Choose below) authorize my minor child age 16 and over to come to appointments by his/herself for medical care.

This authorization shall remain in effect until it is revoked by me.

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.

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