ALTERNATE CARE AND INFORMATION SHARING AUTHORIZATION

It is the policy of Health Care for Children NOT to provide treatment or other services to children unaccompanied by a parent or legal guardian. If desired, the parent or legal guardian may authori ze others such as grandparents, babysitters, etc. to bring the patient to our office for care. An older adolescent patient (16 years of age or older) may be permitted to present to the office unaccompanied if permission is granted by a parent or legal guardian . This authorization form also grants our staff the permission to share information with the individuals listed below. Please check one or more of the following.

I authorize the following person/persons to bring the patient listed below for medical treatment including any immunizations or other necessary treatment. I understand the signature of the listed individual(s) will obligate me to any applicable charges and is a surrogate for my own signature.

I authorize the adolescent patient (age 16 or o lder) listed below to present unaccompanied for treatment if allowed by law.

I, the patient listed below, hereby give permission to share my health information (excluding information I have identified as confidential unless required by law or insurance billing) with the person(s) listed below.

Name:

Relationship:

Add new row

Expiration Date:

None (perpetual)

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.

Patient's Name:

Patient's Date of Birth:

Name of Patient, Parent, or Legal Guardian:

Relationship:

Today 's Date:

Your information will be encrypted.