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:
Child's Health Information
Current prescribed or over-the-counter medications and dosages: