Healthcare Child Document

Consent for Medical Treatment of Minor and HIPAA Authorization

Patient (Child) Information

Child Name:

Date of Birth:     Gender:

Parent / Legal Guardian Information

Insurance Information

Medical History

Proposed Procedure, Treatment, or Service

I authorize clinicians, staff, and other agents of the treating facility to perform the procedure(s) or provide the treatment(s) described above, including such routine diagnostic or therapeutic means as are necessary in the professional judgment of the treating clinician. I understand that no guarantees have been made to me as to the results of the procedure(s) or treatment(s).

I acknowledge that the treating clinician has explained the nature, purpose, reasonable alternatives, and material risks associated with the proposed treatment, including the risks of not proceeding. I understand I may ask questions and receive answers to my satisfaction prior to giving consent.

I authorize the administration of medication, immunizations, anesthesia, or other necessary interventions as indicated for the child’s care in connection with the authorized treatment. In the event of an emergency, I authorize emergency medical treatment as required to preserve the life or health of the child.

Authorization to Disclose Protected Health Information (HIPAA)

I authorize the facility to use and disclose the child’s protected health information as necessary for treatment, payment, and healthcare operations. I further authorize disclosure of the child’s medical information to the following persons or entities for the purposes of communicating results, treatment plans, or billing:

This authorization permits the facility to release summaries, treatment plans, and billing information to the individuals named above. I understand that I may revoke this authorization in writing at any time except to the extent that action has already been taken in reliance upon it.

Financial Responsibility and Consent

I accept financial responsibility for charges not covered by insurance. I authorize assignment of benefits to the facility and direct payment from insurer to the facility where permitted. I understand that I may be responsible for co-payments, deductibles, and non-covered services.

I acknowledge the right to withdraw this consent at any time by providing written notice to the facility, except where action has already been taken in reliance on this consent.

Signatures and Certification

By signing below I certify that I am the parent or legal guardian of the named child and that I have the authority to consent to the treatment described above. I have read and understand the foregoing information and consent to the provision of care as indicated.

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