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Pediatricians in Lone Tree, CO at Lone Tree Pediatrics  Form

Pediatricians in Lone Tree, CO at Lone Tree Pediatrics Form

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Form will need to be updated annually and any changes must be made in writing. CONSENT TO PERMIT CERTAIN INDIVIDUALS TO ACCOMPANY CHILD REN FOR TREAMENT I hereby authorize the following individual s to accompany my child ren to Lone Tree Pediatrics for the provision of medical services and to view or discuss my child ren s Protected Health Information PHI. Com Website lonetreepediatrics. com PARENT/GUARDIAN PRE-AUTHORIZATION TO PROVIDE MEDICAL CARE TO AN UNACCOMPANIED PATIENT In order to...
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