Healthcare Kids Net Release Form

HEALTHCARE KIDS NET RELEASE FORM

Child Name:    Date of Birth:    Gender:

Patient / Child Information

Emergency Contact

Insurance Information

Medical History

Immunizations current and on file:

Consent, Release and Authorizations

I, the undersigned parent or legal guardian, hereby give permission for my child named above to participate in programs and services provided by Healthcare Kids Net (the Program). I understand participation may include educational activities, consultations with health professionals, and health screening. By signing below I acknowledge that I have read and understand the terms set forth in this Release Form.

Release of Liability: I hereby RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE the Program, its officers, employees, agents, and volunteers from liability for any injury, illness, or loss that may result from my child's participation, except for such loss or injury as is caused by the Program's gross negligence or willful misconduct.

Assumption of Risk: I understand that participation carries inherent risks. I knowingly and voluntarily assume all risks associated with my child's participation, whether known or unknown.

Authorization for Emergency Medical Treatment: In the event of an emergency, I authorize Program personnel to obtain necessary medical care for my child and to consent to any medical treatment deemed necessary by licensed medical personnel. I agree to be responsible for costs of such care.

Authorization to Share Health Information: I authorize release of relevant medical and immunization information for coordination of care among Program staff, health care providers, and other authorized personnel on a need-to-know basis. This authorization is limited to information reasonably necessary for treatment, referral, billing, and program administration.

I consent to emergency medical treatment as described above.

I consent to the sharing of my child's medical and program-related information as described above.

I consent to the use of photographs, video, or other media that include my child for Program-related educational or promotional materials. I understand no identifying contact information will be published without separate written consent.

I consent to my child being transported by authorized Program personnel for Program activities or medical care when necessary.

HIPAA / Privacy Acknowledgment

I acknowledge that I have been informed of the privacy practices of the Program. I understand that my child's protected health information may be used and disclosed for treatment, payment, and health care operations as permitted by law. I understand my rights regarding access to and amendment of my child's health information and that I may request restrictions on certain uses and disclosures.

I authorize the Program to communicate with me regarding appointment reminders, results, and program information via telephone, voicemail, or electronic message at the contact numbers and address I have provided.

Parent/Guardian certifies that they are the legal guardian or parent of the child named above and have authority to sign this Release. By signing below, Parent/Guardian acknowledges understanding of all terms and verifies that the information provided is true and complete to the best of their knowledge.

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