Healthcare Kidscare Document

HEALTHCARE KIDSCARE DOCUMENT

This Healthcare Kidscare Document combines patient intake, authorization for treatment, medical history disclosure, privacy acknowledgment, and limited release and consent for minors. By signing below, the undersigned certifies authority to act on behalf of the minor patient, consents to necessary medical care and emergency treatment, authorizes release of medical information as described, and acknowledges the privacy and administrative terms set forth herein.

Patient Information

Date of Birth:    Gender:    Preferred Pronouns:

Parent / Guardian Information

Emergency Contact

Insurance Information

Medical History & Current Health

Date of last immunizations (if known):

Authorization for Treatment and Consent

I, the undersigned parent or legal guardian, hereby authorize licensed medical personnel, nurses, technicians, and agents of this facility to provide routine and emergency medical care for the minor named above. Routine care may include physical examinations, vaccinations, administration of prescribed medications, first aid, diagnostic testing, and minor procedures commonly performed in outpatient pediatric care.

In the event of an emergency when I cannot be reached, I authorize the provider to take any action deemed necessary for the health and safety of the minor, including transport to an appropriate medical facility and emergency surgery if warranted. I understand efforts will be made to contact me prior to non-emergent procedures where practicable.

This consent is valid for care related to acute illness or injury and routine pediatric care while the child is registered with this practice unless revoked in writing. Authorization expiration date (if any):

HIPAA & Privacy Acknowledgment

I acknowledge that I have received or been offered the clinic's Notice of Privacy Practices describing how medical information about the minor may be used and disclosed. I authorize the clinic to use and disclose protected health information for treatment, payment, and healthcare operations as permitted by law and as needed for continuity of care.

I specifically authorize disclosure of health information to the following individual(s) for the purpose of care coordination and appointment scheduling:

Photo / Video and Marketing Consent (Optional)

I grant permission for non-identifying photographs or video recordings of the minor to be taken for the purposes of medical documentation, education, or internal quality improvement. I understand that identifiable photographs or recordings will not be used for public marketing, advertising, or social media without a separate written authorization.

Consent to non-identifying photo/video:   Check to consent

Medication Administration & Special Instructions

I authorize administration of over-the-counter medications commonly used in pediatric care (e.g., acetaminophen, ibuprofen, topical antiseptics) as indicated by clinical staff according to dosing guidelines unless otherwise noted below.

Authorization to Release Medical Records

I authorize the release of medical records for the minor to other healthcare providers, insurance carriers, or designated representatives for continuity of care and claims processing. This authorization includes immunization records and pertinent treatment summaries but does not authorize release of psychotherapy notes or other specially protected records unless expressly indicated below.

Administrative Acknowledgements

I understand that I am financially responsible for charges not paid by the insurer. I authorize release of information necessary to process insurance claims and assign benefits to the provider where permitted. I acknowledge that providing false information is subject to applicable penalties.

I understand that this document is a legal authorization. I may revoke this authorization at any time in writing except to the extent that action has already been taken in reliance on it. Revocation will not affect disclosures already made under this authorization.

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