Permission to treat a minor

Please correct the errors described below.

I

give permission to my child

to attend his/her illness appointment alone without my presence and authorize treatment for my child in accordance with the office policy of Pediatric Health Care Associates. This includes providing a history of present illness, disclosure of protected health information, and responsibility for relaying any diagnosis, treatment plan, or prescription(s) to the parent or legal guardian mentioned above. I agree to be available by phone and to be financially responsible for all copays and coinsurance.

This Authorization is effective on:

and expires

Child's Health Information

Current prescribed or over-the-counter medications and dosages:

Add another medication

Emergency Contact Information for Parents/Guardians

Temporary Guardian Information

Insurance Information

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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