Notice of Privacy Practices Receipt of Acknowledgement and Consent for Treatment
My signature acknowledges I have been offered/received a copy of Omaha Children's Clinic P.C.'sHIPAA Privacy Practices for my review.
My signature also confirms I consent to medical care for myself at Omaha Children's Clinic, P.C, including all examinations, assessments, tests, therapy, outpatient diagnostic procedures including laboratory and radiology procedures, and other services and procedures that the physicians, other health care providers, and staff of this clinic deem necessary or appropriate. I understand the practice of medicine is not an exact science and no guarantees have been made to me regarding medical care.
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.
* This form is valid until revoked by patient or patient reaches the age of 22 *
Delegation of Consent
I hereby authorize the following individual(s) to consent to any and all medical care and attention deemed necessary and appropriate for me by a healthcare provider licensed in the state of Nebraska when I am unable to do so for myself. I also consent to clinic communications regarding my care with the individual(s) below. This consent includes, but is not limited to, medical and surgical intervention and elective as well as emergency care.This delegation shall be valid until I withdraw delegation of consent.