Parent and Minor Confidential Agreement

The state of Maryland grants minors the right to confidential medical care regarding contraception, pregnancy, and sexually transmitted disease testing and treatment. We encourage full communication between a minor and her legal guardian.

Whether or not this supplemental form is signed, we will uphold the state and federal laws regarding confidential health care information.

Parent

I, (parent or guardian)

allow my daughter, (patient)

to enter a confidential patient-physician relationship. I understand that my daughter can make independent health care decisions, but that my input and involvement will be encouraged.

My daughter has permission to schedule appointments and receive confidential reports from this office, I further understand that various laboratory tests may be necessary in medical protocols and accept responsibility for physician charges and laboratory fees.

Parent or Guardian

Physician

Date

Patient

I, (patient)

am entering a confidential physician-patient relationship with (physician),

I will make an effort to communicate with my parent(s) about issues concerning my health. I accept the personal responsibility of being honest and will follow the health care recommendations my physician and I establish.

Patient

Physician

Date

Permission to Treat Minor Patient without Parent/Legal Guardian Present

Today's Date

Capital Women’s Care must receive permission, from a child’s parent or legal guardian, prior to providing treatment(s)for preventative care, injury or illness that is non-life threatening. This form provides the legal permission to (depending on the minor's age) either treat without any adult present (Section A), or with a Designated adult present (Section B)

Patient's Name

Patient's DOB

Section A: (ONLY for child at least 16, but not 18 years old)

Authorization to treat your minor child in case you or your designated representative are unable to accompany your child to one of his/her visits:

I, grant Capital Women's Care, L.L.C. permission to assess and treat the aforementioned minor without an adult present. I also agree to be financially responsible for payment of all charges in connection with the care and treatment rendered.

Section B: (for child under 18 years old)

Delegation of authority for medical treatment of a minor child to the designated representative indicated

Below: I, grant Capital Women’s Care, L.L.C. to assess and treat the aforementioned minor in the presence of either of the following adults (you may choose more than one), who is authorized to approve treatment:

Add Authorized Person/Adult

I also agree to be financially responsible for payment of all charges in connection with the care and treatment rendered.

NOTE: A parent / legal guardian MUST be present for a minor patient’s first visit with Capital Women’s Care.

Formatted text

This authorization is valid for (length of time)

This visit only (date of appointment)

Until otherwise revoked: (Initial)

Please Note: Insurance card(s) and co-pay amounts (if applicable) must be presented at each visit.

Authorized By

Date

Parent or Legal Guardian

Emergency Contact Phone #1

Emergency Contact Phone #2

NOTE: Annotated Code of (State Law) allows for the following exceptions, where a minor has the same capacity as an adult to consent to medical treatment:

Treatment for and/or advice about drug abuse, alcoholism, venereal disease, or pregnancy other than sterilization.
Physical exam for and treatment of injuries and/or collection of evidence from an alleged rape or sexual offense.
Consultation, diagnosis and treatment of a mental or emotional disorder.

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