Patient Permission Form

I have agreed to allow certain individuals to participate in the discussion and decisions to my child/children’s medical care. As well to grant permission for the individuals to be able to act on my behave in case I’m not present at doctor’s appointments. Therefore, I hereby give my permission for Atlanta Pediatric Partners, PC to disclose my personal medical information to the following individuals:

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Conditions for Disclosure:

(Check item(s) that apply)

The practice may disclose my personal health information to the individual(s) above in

The practice may disclose my personal health information to the individual(s) above in discussions during my presence and when I am not physically present, including disclosures by telephone, fax, email or regular mail.

Other conditions of disclosure:

I understand that his consent may be revoked at any time by written notice to the practice.

Patient’s Name:

Date of Birth:

Parent’s Name:

Parent’s Signature:

Date:

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