Southlake - Notice of Privacy Practices

Kidsville Pediatrics PLLC Notice of Privacy Practices

Health (HITECH) Act are federal government regulations designed to ensure privacy and security of patient ́s protected health information (PHI). They ensure that you are aware of your rights and how your medical information can be used in providing and arranging your medical care.

Kidsville Pediatrics PLLC is furnishing you with its Notice of Privacy Practices, which are available in hard copy or at the company’s website or in office at your request. By signing this form, you acknowledge that you have received Kidsville Pediatrics PLLC Notice of Privacy practices.

Consent to Treat

Do hereby give my authorization and consent my child (named above) to be seen by Dra. Naureen Ameen (Kidsville Pediatrics PLLC),and/or any physician or nurse practitioner at Kidsville Pediatrics PLLC, consent to the medical/surgical care, vaccinations, and treatment of my child. Additionally, I hereby authorize and grant that the below named person(s) has/have permission from the natural parents to sign for any medical or surgical procedures, treatments, or immunizations deemed necessary for the well-being of my child(ren). This is also permission to bring my child(ren) for well checks and all necessary immunizations, labwork, or rapid testing that are routinely given at the well visit or any sick visit. The duration of this consent is indefinite and continues until revoked in writing.

I am, by this document, representing that I have the authority to consent for all medical/surgical care and treatment of said child(ren):

Authorized Person(s):

If yes, please provide documentation at the first appointment.