Healthcare Parent Memorandum

HEALTHCARE PARENT MEMORANDUM

This Healthcare Parent Memorandum documents parental or legal guardian instructions, authorizations, and acknowledgements related to the medical care of the minor patient identified below. The undersigned represents that they are the parent or legal guardian with authority to provide the consents and acknowledgements set forth herein.

Patient Information

Patient Name:    Date of Birth:    Medical Record / Patient ID:

Parent / Legal Guardian Information

Emergency Contact (if different)

Insurance Information

Medical History & Current Status

Authorizations and Scope of Consent

By signing below, the parent or legal guardian grants the following authorizations with respect to the minor patient named above. The undersigned affirms they have legal authority to provide these consents.

  Authorize routine medical care, examinations, diagnostic testing and immunizations that are customary for age and presenting condition.

  Authorize emergency medical treatment, including administration of medications, stabilization, and transfer to an appropriate facility if necessary when parent/guardian cannot be reached.

  Authorize non-emergent procedures and treatments as deemed necessary by treating clinicians. I understand that separate specific consent may be required for major surgery or procedures with significant risk.

  Authorize administration of recommended immunizations as appropriate for the patient’s age and medical history.

HIPAA Privacy and Release of Medical Information

I authorize the health care providers and facility treating the patient to disclose protected health information to the parent/legal guardian and to any designated persons listed above, to the extent necessary for treatment, payment, or health care operations. I understand that certain records (for example, psychotherapy notes) may have special protections and will only be disclosed as permitted by law.

This authorization is voluntary but is necessary for the providers to honor the access and consent privileges granted in this Memorandum. I understand that I may revoke this authorization at any time by providing written notice, except to the extent that the provider has already acted in reliance on this authorization.

Emergency Treatment Authorization

If the undersigned parent/legal guardian cannot be reached after reasonable efforts, the undersigned authorizes the treating facility and clinicians to provide any and all medical care deemed necessary for the health and safety of the minor patient, including stabilization and transfer to an appropriate facility. The undersigned agrees that the facility and its personnel may rely on this authorization and will not be liable for actions taken in good faith reliance on this Memorandum.

Revocation and Amendment

This Memorandum remains in effect until the stated expiration date or until revoked in writing by the undersigned. Revocation or amendment must be delivered to the treating facility in writing and will be effective upon receipt by the facility, except to the extent the facility has already acted in reliance on the existing authorization.

Acknowledgment and Certification

I certify under penalty of perjury that I am the parent or legal guardian of the minor patient named above, that the information provided in this Memorandum is true and correct to the best of my knowledge, and that I have the authority to grant the authorizations contained herein. I acknowledge that I have read and understand the statements above and that I have had the opportunity to ask questions about the content of this Memorandum.

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