Consent To Use & Disclose Health Information

This office is required by Federal Regulations to inform our Patients in regards to the use of your child’s health information in accordance to Health Insurance Portability & Accountability Act of 1996 or HIPAA.

PLEASE READ THE FOLLOWING CAREFULLY!

I understand that as part of my child’s health care, Young Pediatrics originates and maintains paper and/or electronic records describing my child’s health history, symptoms, examination and test results, diagnoses, treatments, and any plans for future care or treatment. I understand that this information serves as:

• A basis for planning care and treatment
• A means of communication among health professionals who contribute to my child’s care.
• A source of information for applying diagnosis and treatment information to my bill.
• A means by which a third-party can verify the services billed to me actually took place.

I understand and have been provided access to a Notice of Privacy Practices that provides a more complete description of information uses and disclosures. This notice is located in the waiting area in plain view. I understand that I have the following rights and privileges:

• The right to review the Notice of Privacy Practices prior to signing this consent, allowing treatment, or making payment for services rendered.
• The right to object to the use of my child’s health information for directory purposes.

I understand that Young Pediatrics is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization may refuse to treat my child as permitted by Federal Regulations. I understand that Young Pediatrics reserve the right to change their Notice of Privacy Practices. I further understand that Young Pediatrics may use a computerized state vaccine registry to track immunization requirements and maintain immunization records. Young Pediatrics may enroll patients unless you inform us in writing that you do not wish to participate.

Please note that I consent to the following uses of my child’s medical information (Initial Below)

I understand that as part of this organization’s treatment, payment, or health care operations, it may become necessary to disclose my child’s protected health information to another entity. I hereby consent to such disclosure for these permitted uses. I also hereby consent to such disclosures via fax.

I fully understand and accept the terms of this consent.

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.

The Importance of Immunizing Children: Our Practice Policy

We firmly believe in the effectiveness of vaccines to prevent serious illness and to save lives.

We firmly believe in the safety of our vaccines

We firmly believe that all children and young adults should receive all of the recommended vaccines according to the schedule published by the Centers for Disease Control and the American Academy of Pediatrics.

We firmly believe, based on all available literature, evidence, and current studies, that vaccines do not cause autism or other developmental disabilities. We firmly believe that thimerosal, a preservative that has been in vaccines for decades and remains in some vaccines, does not cause autism or other developmental disabilities.

We firmly believe that vaccinating children and young adults may be the single most important health-promoting intervention we perform as health care providers and that you can perform as parents/caregivers. The recommended vaccines and their schedule given are the results of years and years of scientific study and data gathering on millions of children by thousands of our brightest scientists and physicians.

These things being said, we recognize that there has always been and will likely always be controversy surrounding vaccination. Indeed, Benjamin Franklin, persuaded by his brother, was opposed to the smallpox vaccine until scientific data convinced him otherwise. Tragically, he had delayed inoculating his favorite son, Franky, who contracted smallpox and died at the age of 4, leaving Ben with a lifetime of guilt and remorse. Quoting Mr. Franklin’s autobiography:

In 1736, I lost one of my sons, a fine boy of four years old, by the smallpox…I long regret bitterly, and still regret that I had not given it to him by inoculation. This I mention for the sake of parents who omit that operation, on the supposition that they should never forgive themselves if a child died under it, my example showing that the regret may be the same either way, and that, therefore, the safer should be chosen

The vaccine campaign is truly a victim of its own success. It is precisely because vaccines are so effective at preventing illness that we are even discussing whether or not they should be given. Because of vaccines many of you have never seen a child with polio, tetanus, whopping cough, bacterial meningitis or even chickenpox, or known a friend or family member whose child died for one of these diseases. Such success can make us complacent or even lazy about vaccinating. But such an attitude, if it becomes widespread, can only lead to tragic results.

Over the past several years, many people in Europe have chosen not to vaccinate their children with the MMR vaccine after publication of an unfounded suspicion (later retracted) that the vaccine caused autism. As a result of under immunization, there have been small outbreaks of measles and several deaths from complications of measles in Europe over the past several years

We are making you aware of these facts not to scare you or coerce you, but to emphasize the importance of vaccinating your child. We recognize that the choice may be a very emotional one for some parents. We will do everything we can to convince you that vaccinating according to the schedule is the right thing to do. However, should you have doubts, please discuss these with your health care provider in advance of your visit. In some cases, we may alter the schedule to accommodate parental concerns or reservations. Please be advised, however, that delaying or “breaking up the vaccines” to give one or two at a time over two or more visits goes against expert recommendations and can put your child at risk for serious illness (or even death) and goes against our medical advice as providers at Young Pediatrics. Such additional visits will require additional co-pays on your part. Furthermore, please realize that you will be required to sign a “Refusal to Vaccinate: acknowledgment in the event of lengthy delays.

Finally, if you should absolutely refuse to vaccinate your child despite all our efforts, we will ask you to find another health care provider who shares your views. We do not keep a list of such providers nor would we recommend any such physician. Please recognize that by not vaccinating you are putting your child at unnecessary risk for life-threatening illness and disability, and even death.

As medical professionals, we feel very strongly that vaccinating children on schedule with currently available vaccines is absolutely the right thing to do for all children and young adults. Thank you for your time in reading this policy, and please feel free to discuss any questions or concerns you may have about vaccines with any one of us.

The vaccine schedule is subject to change but will always be in compliance with AAP and ACIP/CDC recommended vaccine schedule.

I have read and understand the Vaccine Policy Statement.

By signing below, you acknowledge and understand our collection policy and that all costs are the responsibility of you 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.