Pediatric & Adolescent Associates
I, name stated above, the parent/legal guardian of the below named child(ren),
Hereby authorize and consent to the examination and/or treatment of my child(ren) during office and facility visits by the physicians and clinical staff of Pediatric & Adolescent Associates. In addition, I give permission for the following person(s) to bring my child to PAA in my absence and to act on my behalf in authorizing medical care and treatment in my absence. In the event of an emergency or other illness, I understand that the physicians and staff of PAA will deliver any medical care deemed necessary regardless of the accompanying adult. Unless we are notified in writing, PAA will assume that a child's biological and/or legal parents are both legal guardians who have access to treatment options and medical information for that child.
At Pediatric & Adolescent Associates, we are committed to protecting the security and privacy of your child's personal information. Medical records are the property of PAA, kept in a secure location, and are accessed for only purposes outlined by the Notice of Privacy Practices. Records may be released or shared with other health care providers for treatment of your child. Patients are entitled to one free copy of their medical records only after an authorization for release is signed.
By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
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