Healthcare GSRP Consent Form

HEALTHCARE GSRP CONSENT FORM

Patient Information

Date of Birth:    Gender:

Phone:    Email:

Emergency Contact

Relationship:    Phone:

Insurance Information

Policy/ID #:    Group #:

Subscriber Date of Birth:

Medical History

Consent for GSRP Health Services

I hereby authorize designated GSRP clinical personnel to provide the following services to the patient named above. I understand that these services are voluntary, that I may refuse consent, and that I may withdraw consent at any time by providing written notice to program staff.

Routine health screenings (height, weight, growth/development monitoring, vision and hearing screening)
Administration of routine immunizations as recommended and documented in the patient's record (parent/guardian will be informed prior to administration whenever practicable)
Administration of prescribed medications and approved over-the-counter medications per program protocol (medication details must be provided in current_medications)
Emergency medical treatment if necessary, including first aid and transport to an emergency facility when clinically indicated
Release of relevant medical information to program staff, consulting providers, and partner agencies for coordination of care
Transport to/from authorized off-site medical appointments and program activities when required for care
Photographs or video for treatment documentation or internal program use (no public release without separate permission)

Risks and Benefits: I understand the nature and purpose of the services. While screening and routine care are generally safe, risks may include minor discomfort, allergic reaction to vaccines or medications, or rarer complications. Benefits may include early detection of health concerns and timely treatment.

Voluntary Participation and Revocation: Consent is voluntary. I may revoke this authorization at any time by delivering a written revocation to program staff, except to the extent that action has already been taken in reliance on this consent.

HIPAA Authorization & Privacy Acknowledgment

I acknowledge that I have been given the opportunity to review the program's Notice of Privacy Practices describing how protected health information (PHI) will be used and disclosed. By signing this form I authorize the use and disclosure of PHI as necessary to provide care, billing, and care coordination with other health providers and agencies consistent with treatment and payment.

I acknowledge receipt of the Notice of Privacy Practices and authorize the disclosure of PHI as described above.

Authorization Expiration Date: . If left blank, this authorization will remain in effect until revoked in writing or until the patient is no longer enrolled in GSRP services.

Minors: If the patient is under 18 years of age, consent must be provided by a parent or legal guardian. By signing below, I certify that I am the patient or the patient's parent/legal guardian and have authority to grant the consents indicated.

Legal Certification

I certify under penalty of perjury that the information provided on this form is true and correct to the best of my knowledge. I understand that falsification of information may affect the provision of services. I release the program and its agents from liability for carrying out the consents as authorized, except for willful misconduct or gross negligence.

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