I authorize Kid Approved Pediatrics, PLLC to provide treatment to the below named patient.
Reference Laboratory Services
I understand that Kid Approved Pediatrics, PLLC utilizes the services of an outside lab to perform some of the lab tests requested by its physicians. I further understand that the Reference Laboratory will bill separately for its services. I consent to Kid Approved Pediatrics, PLLC and providing demographic information as necessary for billing purposes.
Assignment of Benefits
I authorize my insurance company to pay and hereby assign directly to Kid Approved Pediatrics, PLLC, all benefits, if any, otherwise payable to me for services. This authorization may be revoked by either me or my insurance company at any time in writing.
Authorization for Release of Medical Information
I authorize release of copies of pertinent medical records to providers outside of Kid Approved Pediatrics, PLLC who are being consulted with and/or I am being referred to in connection with my current treatment, to insurance companies for the purpose of determining benefits for services provided, and to reference laboratories for billing purposes.
Authorization for Release for Quality Improvement
Texas Law requires us to inform you that a copy of your medical record, no matter when created, may be release to outside groups for medical research or quality improvement purposes unless you object. Researchers cannot use patient names or identifying characteristics when reporting any results of their research. We evaluate these requests to ensure that the release of patient records is necessary to accomplish the research purpose.
Authorization for Review of Prescription History
I authorize Kid Approved Pediatrics, PLLC to access my electronic records of previously prescribed medications through external electronic prescribing network, sure scripts.
Use of Disclosure of Protected Health Information
My insurer may share my past, current and future health and account records with Kid Approved Pediatrics, PLLC about services I've received from Kid Approved Pediatrics, PLLC and other care providers unrelated to Kid Approved Pediatrics, PLLC. These records may be used by Kid Approved Pediatrics, PLLC as needed to manage or coordinate my care and to improve the quality of that care. By signing this form, I am consenting to treatment, and agreeing to all above policies. I understand this authorization will remain in effect until I revoke it in writing.
By printing your name in the signature box, this is confirmation of e-signature.