Omaha Childrens Clinic Communication Consent

Telephone Messages

As parent/guardian, I give Omaha Childrens Clinic P.C. permission to leave relevant, detailed telephone messages regarding my child(ren)’s care and follow up, including test results, on my answering machine when I am not available at the following phone numbers provided:

I DO NOT give Omaha Childrens Clinic P.C. permission to leave detailed telephone messages regarding my child (ren)’s care when I am unavailable. I will return the phone call.

Text Appointment Reminders: This is an automated text reminder of your child's appointment 1-3 days in advance. This feature would replace the reminder calls you now receive. We require one cell phone number on file to enable this feature.

DISCLAIMER: By providing your mobile number below, we may contact you via text message; standard message and data rates apply. Reply stop to opt-out.

Name

Relationship

Primary #

Secondary #

Patient Portal

The patient portal is a service that allows parents/guardians to retrieve selected patient information, complete provider paperwork and communicate directly with our staff.

We do not sell or give away any protected health or contact information. We reserve the right to suspend or terminate the Patient Portal account at any time and for any reason without notice.
Please note that the Patient Portal is not checked for messages on weekends or holidays.
By using the Patient Portal, you agree to protect your password from unauthorized individuals. It is your responsibility to notify us if your password gets lost or stolen, we will reactivate a new account for you.
You agree to not hold OCC responsible for any network infractions beyond our control.

Email Address

Divorce Policy

We believe that divorce, separation and custody agreements should not enter into a child's medical treatment. The parent who is requesting the medical treatment is individually responsible for the payment of the medical bills. We are not a party to your divorce agreement we will collect co-pays and deductibles for the attending parent.

"Joint Custody" means that each parent has equal access to the child's medical record. Without a court order, we will not stop either parent from looking at their child's chart or obtaining their child's test results. In the circumstance of joint custody, we will not call the other parent for consent prior to treatment or to inform the non-present parent of the assessment and/or plan of care, if any. Again, we will discuss with the accompanying parent, information pertinent to the child's history and/or present exam. It is then the responsibility of the parents to communicate with each other.

We reserve the right to charge an administrative fee for copying records should the requests become excessive. Should issues between the parents become disruptive to our medical practice, we reserve the right to discharge a family from our care and responsibility.

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.

Signature

Date

I understand that this authorization for disclosure is in effect until I choose to have it revoked, and I may do so at any time.

Your information will be encrypted.