Healthcare ChildCase Form

Healthcare ChildCase Form

Child Information

Date of Birth:    Gender:    Child Preferred Name/Nickname:

Parent / Legal Guardian Information

Relationship to Child:    Primary Phone:    Alternate Phone:

Insurance Information

Policy/Member ID:    Group Number:    Subscriber Name:

Emergency Contact

Relationship:    Phone:

Medical History

Please indicate if the child has any of the following conditions (check all that apply):

Asthma    Diabetes    Seizure disorder    Heart condition

ADHD    Developmental delay    Other:

Medications & Allergies

Immunizations & Preventive Care

Immunization Status: Up to date    Partial    Unknown

Developmental / Behavioral

Consent for Treatment

I, the undersigned parent or legal guardian, authorize the healthcare providers and clinical staff of this practice to provide routine medical care, examinations, vaccinations, diagnostic testing, administration of medications, and emergency treatment to the minor child named in this form. I understand that no specific guarantee has been made as to the results of any treatment or procedure. I authorize clinicians to perform such services as are, in their professional judgment, necessary for diagnosis and treatment.

I acknowledge that I have been informed of the nature, anticipated benefits, and material risks associated with routine treatments and vaccinations offered. I understand I may refuse any treatment or immunization on behalf of the child unless otherwise required by law. I authorize emergency transport and treatment if the provider determines such action is necessary to prevent serious harm.

Consent for routine care and non-emergent vaccinations: I authorize routine care and indicated immunizations for this child.

Consent for emergency care and transport: I authorize emergency medical care and transport if deemed necessary.

Authorization to Release Medical Information

I authorize the release of the child's medical information, including immunization records and treatment summaries, to the following persons or entities as needed for treatment, care coordination, school/daycare documentation, or insurance claims:

Purpose of disclosure:

Restrictions:

HIPAA Acknowledgment & Privacy

I acknowledge receipt of the practice's Notice of Privacy Practices and understand that the practice may use and disclose protected health information for treatment, payment, and health care operations as permitted by law. I understand I may request restrictions on uses and disclosures, and that such requests must be submitted in writing. I authorize release of necessary information to insurers and third-party payers for claims and to coordinate care.

Permission to discuss child's care with listed contacts: I permit staff to discuss the child's protected health information with designated persons listed on this form.

Authorization Duration & Revocation

This authorization is valid until:    No expiration (until revoked)

I understand that I may revoke this authorization at any time by submitting a written revocation, except to the extent that action has already been taken in reliance on this authorization. Revocation will not affect disclosures already made under this authorization prior to receipt of revocation.

Certification & Financial Responsibility

I certify that the information provided on this form is true and complete to the best of my knowledge. I accept financial responsibility for services provided to the child and understand that I am responsible for any charges not covered by insurance, including co-payments, deductibles, and services denied by the insurer. I authorize assignment of benefits to the provider for insurance payment.

I understand that if I have questions about any procedure, treatment, or vaccine, I may ask the provider to explain the risks and benefits before consenting.

Additional Information

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