Delegation of Consent

I hereby authorize (when I am unavailable to give consent) the following individual(s):

To consent to any and all medical care attention deemed necessary and appropriate for this minor by a healthcare provider licenses in the state of Nebraska. This consent includes, but is not limited to, medical and surgical intervention and elective as well as emergency care. This delegation shall be valid until I withdraw delegation of 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.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES/USE AND DISCLOSE FORM

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information (PHI) about you. We provide this form to comply with the Health Insurance Portability and Accountability Act (HIPAA). A copy of our Notice is available upon request. Please review the Notice of Privacy Practices thoroughly before signing this acknowledgement form. If terms or our Notice change, a revised copy will be made available.

By signing this form, you acknowledge that our practice may use and disclose PHI about you for treatment, payment, and healthcare operations. You have the right to request that we restrict how PHI about you is used or disclosed for treatment, payment, or healthcare operations.