Kidsville Pediatrics 1759 Broad Park Circle South, Suite 201 Mansfield, TX 76063
Parent/ Guardian #2
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Thank you for choosing Kidsville Pediatrics as your child’s pediatrician and as one of our patients we would like you to be aware of our financial policies. Once you have carefully read the following please sign this document and return to our office staff.
DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
The Health Insurance Portability Act (HIPAA) and the Health Information technology for Economic and Clinical 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 for, you acknowledge that you have received Kidsville Pediatrics PLLC Notice ofPrivacy practices.
Do hereby give my authorization and consent my child (named above) to be seen by Dr. Naureen Ameen (Kidsville PediatricsPLLC),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, lab work, 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):
INFORMATION REQUESTED FROM (CLINIC NAME)
SEND INFORMATION TO
Name: Kidsville Pediatrics
Address: 1759 Broad Park Circle South, Suite 201 Mansfield, TX 76063
Phone: (682) 341-3910 FAX: (682) 400-1288 Email: office@kidsvillepeds.net
I, (Please input Name below), hereby grant permission for you to release confidential health information about me, or my child, by releasing a copy of my medical record, or a summary of my protected health information, to Kidsville Pediatrics.
(ImmTrac2) Minor Consent Form
*Children younger than18 years old only
The Texas Immunization Registry (ImmTrac2) is a free service of the Texas Department of State Health Services (DSHS). The immunization registry is a secure and confidential service that consolidates and stores your child’s (younger than 18 years of age)immunization records. With your consent, your child’s immunization information will be included in ImmTrac2. Doctors, public health departments, schools, and other authorized professionals can access y our child’s immunization history to ensure that important vaccines are not missed.
The Texas Department of State Health Services encourages your voluntary participation in the Texas immunization registry
Consent for Registration of Child and Release of Immunization Records to Authorized Entities
I understand that, by granting the consent below, I am authorizing release of the child’s immunization information to DSHS and I further understand that DSHS will include this information in the state’s central immunization registry (“ImmTrac2”). Once in ImmTrac2, the child’s immunization information may by law be accessed by:
I understand that I may withdraw this consent to include information on my child in the ImmTrac2 Registry and my consent to release information from the Registry at any time by written communication to the Texas Department of State Health Services, ImmTrac Group –MC 1946, P. O. Box 149347, Austin, Texas 78714-9347
By my signature below, I GRANT consent for registration. I wish to INCLUDE my child’s information in the Texas immunization registry.
Parent, legal guardian, or managing conservator:
Privacy Notification: With few exceptions, you have the right to request and be informed about information that the State of Texas collects about you. You are entitled to receive and review the information upon request. You also have the right to ask the state agency to correct any information that is determined to be incorrect. See http://www.dshs.texas.gov for more information on Privacy Notification.(Reference: Government Code, Section 552.021, 552.023, 559.003, and 559.004)
Questions? (800) 252-9152 (512) 776-7284 • Fax: (866) 624-0180 • www.ImmTrac.comTexas Department of State Health Services • ImmTrac2 Group – MC 1946 • P. O. Box 149347 • Austin, TX 78714-9347
PROVIDERS REGISTERED WITH ImmTrac2
Please enter client information in ImmTrac2 and affirm that consent has been g ranted.DO NOT fax to ImmTrac2. Retain this form in your client’s record.
I,_________________________________, _________________ First name, Last name DOB , Parent of children named below:
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Consent to all images and / or video being made of me or my child/dependent not limited to one date of service. I agree that images may be used for social media purposes including Kidsville Pediatrics website, Facebook Page, Newsletter, or Instagram. Kidsville Pediatrics has full rights to use the photo/videos.
I further acknowledge that there were no promises of compensation for such use of medical photo(s) and or video taken by Kidsville Pediatrics, PLLC staff as consented above.
This consent maybe revoked at any time with written request by patient.
By signing below, I confirm that I understand this consent form.
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