Healthcare Consent to Treat Minor

HEALTHCARE CONSENT TO TREAT MINOR

Provider / Facility Information

Provider / Facility Name:

Provider Address:

Patient (Minor) Information

Date of Birth:    Gender:

Primary Phone:    Alternate Phone:

Emergency Contact

Relationship:    Phone:

Parent / Legal Guardian Information

Relationship to Minor:    Phone:

Insurance Information

Policy / ID Number:    Group Number:

Medical History

Consent and Authorization

I, the undersigned parent or legal guardian, hereby authorize the health care providers and staff of the named Provider / Facility to examine, diagnose, and provide routine medical treatment and care to the minor identified above. This authorization includes the following treatments as indicated below. I certify that I have the legal authority to grant consent for medical treatment to this minor.

Routine and preventive care (examinations, testing, minor treatments)

Immunizations and vaccinations as recommended by provider

Diagnostic procedures including laboratory tests and X-rays

Emergency treatment and stabilization if necessary

Surgical procedures or anesthesia if deemed necessary by attending physician (only when emergency or when separate informed surgical consent cannot reasonably be obtained)

I understand that all medical and surgical procedures carry risks. The provider has explained the reasons for the recommended care, the expected benefits, reasonably foreseeable risks, and common alternatives. I have had the opportunity to ask questions and have received answers in a language I understand.

I acknowledge that I may withdraw this consent at any time by providing written notice to the Provider / Facility, except to the extent that the Provider / Facility has already relied upon this authorization in providing care to the minor.

HIPAA / Privacy Acknowledgment

By signing below I acknowledge receipt of the Provider / Facility's Notice of Privacy Practices and authorize the Provider / Facility to use and disclose the minor's protected health information for treatment, payment, and health care operations. I further authorize release of medical information to the insurance carrier(s) named above for claims processing and payment.

I acknowledge I have been provided with the Notice of Privacy Practices and authorize release of medical information as described above.

Authorization Duration and Revocation

This authorization is effective immediately and will remain in effect until:   or until revoked in writing by the undersigned parent or legal guardian.

Certification and Signature

I certify under penalty of perjury that I am the parent or legal guardian of the minor named above, that the information on this form is true and correct to the best of my knowledge, and that I have the authority to give this consent. I understand that signing this form authorizes health care services as indicated above.

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