to attend ill 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, 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.
(Date Authorization is no longer valid)
Child’s Health Information
Currently prescribed or over-the-counter medications and dosages: