Consent to Treat an Unaccompanied Minor

(Name of Legal Guardian)

give permission to my child

(Name of Child Age 16-18 years old)

to attend ill OR well visit appointments alone, without the presence of a legal guardian or authorized adult. I authorize treatment for my child in accordance with the policies of Bloomington Pediatrics, LTD. This includes providing a history of present illness, disclosure of protected health information, and responsibility for relaying any diagnosis, treatment plan, forms or prescription(s) to the parent or legal guardian mentioned above. I agree to be available by phone and to be financially responsible for all copays, deductibles and/or coinsurance resulting from the visit.

This authorization is effective on

(Today’s Date)

and expires..

(Date Authorization is no longer valid)

Child’s Health Information

Currently prescribed or over-the-counter medications and dosages:

Medication:

Dosage:

Add new medications and dosages:

Allergies, illnesses or other comments:

Emergency Contact Information for Parents/Legal Guardians

Where/how can you be contacted in case of emergency?

Phone:

Comments:

Health Insurance Information

*If no change since last accompanied visit, check here and skip to Signature.

If Insurance information has changed, please complete the following and plan to send the card with your child for scanning into their record.

Insurance Company:

Group Number:

Policy Holder:

ID Number:

Policy Holder Address (if different than patient):

Policy Holder Date of Birth:

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.

Parent or Legal Guardian’s Signature:

Date:

Your information will be encrypted.