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As a patient of Pediatric Health and Wellness your child has important rights related to the healthcare he or she receives. Your children are entitled to these rights regarding their sex, culture, economic, educational and religious background. You also have the responsibility to be an informed parent. By understanding your rights and responsibilities your child will receive the maximum benefits of his or her healthcare.

PATIENTS’ RIGHTS: You have the right to:

  • Participate in decisions about your child’s healthcare and treatment plan.
  • Be treated with respect and dignity.
  • Receive from your medical provider complete information about your child’s diagnosis, any proposed procedure or treatment alternatives, including non-treatment, to give informed consent.
  • Refuse any procedure or treatment if you so desire, and to the extent permitted by law, be informed as to what effect this may have on your child’s health.
  • Receive full consideration of privacy and confidentiality regarding all information and records about your child’s healthcare and account.
  • Be informed of the cost of care and treatment and receive an explanation of your financial obligation when required (co payments, deductible, co-insurance).
  • Receive 24-hour access to your Primary Care Physician or covering physician.
  • Receive prompt and reasonable responses to questions and requests.

PATIENTS’ RESPONSIBILITIES: You have the responsibility to:

  • Know the benefits and exclusions of your health insurance coverage.
  • Provide your healthcare provider with complete and accurate health information, including current immunization records.
  • Change Primary Care Physicians to our practice by contacting your health care insurance plan’s member services.
  • Know and provide the cost of your co-pay, deductible or co-insurance at the time of service.
  • Provide current and up-to-date insurance information. Provide patient’s insurance card at time of service.
  • Consent to Treat: as a Primary Care Physician’s office, we treat children under the age of 18 years. If a person other than the parent or legal guardian seeks medical treatment for your child, we must have a letter of consent to treat signed by the parent or legal guardian.
  • If a patient undergoes a legal name change, provide our office with a copy of the court documentation authorizing the change. This will allow us to consider making a name change on your child’s medical chart and/or account.
  • Provide our office with any demographic changes. Demographics provided should be for the parents/parent or legal guardian with whom the child primarily resides.

Please sign and date indicating that you understand your Rights and Responsibilities.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

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