KAP Medical Consent

This consent applies to minors and 18yr +

Please correct the errors described below.

Authorization for Treatment

I authorize Kid Approved Pediatrics to provide treatment to the below named patient.

Reference Laboratory Services

I understand that Kid Approved Pediatrics utilizes the services of an outside lab to perform some of the lab tests requested by its physicians. I further understand that the Reference Laboratory will bill separately for its services. I consent to Kid Approved Pediatrics and providing demographic information as necessary for billing purposes.

Assignment of Benefits

I authorize my insurance company to pay and hereby assign directly to Kid Approved Pediatrics all benefits, if any, otherwise payable to me for services. This authorization may be revoked by either me or my insurance company at any time in writing.

Authorization for Release of Medical Records

I authorize release of copies of pertinent medical records to providers outside of Kid Approved Pediatrics who are being consulted with and/or I am being referred to in connection with my current treatment, to insurance companies for the purpose of determining benefits for services provided, and to reference laboratories for billing purposes.

Authorization for Review of Prescription History

I authorize Kid Approved Pediatrics to access my electronic records of previously prescribed medications through external electronic prescribing network, sure scripts.

Use of Disclosure of Protected Health Information

My insurer may share my past, current and future health and account records with Kid Approved Pediatrics about services I've received from Kid Approved Pediatrics and other care providers unrelated to Kid Approved Pediatrics. These records may be used by Kid Approved Pediatrics as needed to manage or coordinate my care and to improve the quality of that care. By signing this form, I am consenting to treatment, and agreeing to all above policies. I understand this authorization will remain in effect until I revoke it in writing.

Additional Patient

By signing this form, I attest that I have personally read this form (or had it explained to me) and fully understand and agree to its contents.I authorize medical care which is deemed necessary by the physicians and medical providers at KAP at the time of the appointment.

This will be used for contact purposes only

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