Healthcare Parent Letter

HEALTHCARE PARENT LETTER

Provider Name:   Date of Letter:

Patient / Child Information

Child Full Name:

Date of Birth:   Gender:

Primary Phone:   School/Program:   Grade:

Parent / Guardian Information

Relationship to Child:   Primary Phone:

Emergency Phone:   Relationship:

Insurance Information

Policy Number:   Group Number:   Subscriber Name:

Medical History (Summary)

Purpose of This Letter / Requested Actions

Effective Dates (if applicable): From to

Permissions and Authorizations

I authorize the provider named above to provide routine evaluation and medical treatment to the child named in this letter as reasonably necessary for the purpose described. This authorization includes clinical assessment, administration of medications as ordered, and minor procedures customary to outpatient pediatric care.

I authorize the release of medical information related to the care described in this letter to the following parties as needed to facilitate care: school officials, program staff, and emergency medical personnel.

I permit the provider to communicate with school or program personnel regarding accommodations, restrictions, or medication administration required during school or program hours.

I consent to the limited use of photographs or recordings of the child for documentation of treatment or to facilitate school/program accommodations. I understand photographs will not be distributed beyond relevant staff without additional consent.

I consent to the use of telehealth for the provision of services when in-person care is not feasible. I acknowledge telehealth has limitations compared to in-person evaluation and that confidentiality will be protected to the extent possible.

Privacy, Revocation, and Acknowledgments

I acknowledge that I have been offered a copy of the provider's Notice of Privacy Practices describing how my child's protected health information may be used and disclosed. By signing below I authorize disclosures described in this letter in accordance with applicable law.

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

I understand that treatment, enrollment, or eligibility for benefits is not conditioned on signing this authorization except where permitted by law. I further understand that information disclosed pursuant to this authorization may be re-disclosed by the recipient and may no longer be protected by federal privacy regulations.

Additional Instructions / Notes

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