Healthcare Pediatric Consent Form

Healthcare Pediatric Consent Form

Patient Information

Date of Birth:    Gender:

Primary Phone:    Alternate Phone:

Parent/Guardian Information

Relationship to Patient:    Phone:

Relationship:    Phone:

Insurance Information

Policy/ID Number:    Group Number:

Medical History

No known allergies

Consent for Treatment

I, the undersigned parent or legal guardian, hereby authorize licensed physicians, nurses and authorized clinical staff to provide routine medical care, examinations, tests, immunizations, and any indicated diagnostic procedures to the patient named above. I understand and acknowledge that the nature and purpose of the proposed treatment has been explained to me and I have had the opportunity to ask questions.

I understand that all medical procedures involve some risks, which may include but are not limited to infection, bleeding, allergic reaction, or other complications. Reasonable alternatives, anticipated benefits, and foreseeable risks have been explained. I acknowledge the right to refuse any specific procedure and to withdraw this consent at any time by notifying the treating provider in writing, except when the withdrawal would jeopardize the patient’s health in an emergency.

Permission for Emergency Care

If, in the opinion of the attending physician, emergency treatment is necessary for the safety or welfare of the patient and I am not reasonably available to provide consent, I authorize emergency medical treatment and transportation to an appropriate facility. I understand reasonable efforts will be made to contact me or the emergency contact prior to emergency treatment when feasible.

Authorization to Release Medical Information

I authorize the release of medical information to insurance carriers and other entities as necessary for billing, payment, and treatment purposes. I authorize the facility and its representatives to discuss the patient's medical condition and treatment with the following individual(s):

This authorization includes disclosure of behavioral health, substance use disorder, and HIV-related information where applicable unless specifically excluded below.

Exclude disclosure of the following sensitive categories (if any):

HIPAA Privacy Acknowledgment

I acknowledge that I have received or been offered a copy of the facility's Notice of Privacy Practices describing how my child's protected health information may be used and disclosed and how I can obtain access to this information. I understand that signing this form does not guarantee confidentiality in all circumstances and that disclosures permitted by law may be made without further authorization.

I acknowledge receipt of the Notice of Privacy Practices.

Duration and Revocation

This authorization is valid from the date of signature and remains in effect until: , unless earlier revoked in writing. I understand that a written revocation will not apply to actions already taken in reliance on this authorization.

Financial Responsibility

By signing, I accept financial responsibility for charges not covered by insurance, including deductibles, coinsurance, and non-covered services. I authorize insurance benefits to be paid directly to the provider and understand that I may be billed for any remaining balance.

Additional Authorizations (Optional)

I consent to the use of non-identifying photographs or video for treatment documentation, education, or quality improvement.

I authorize staff to arrange transportation for my child if necessary in an emergency.

Certifications

I certify that I am the parent or legal guardian of the patient named above and that I have the authority to consent to medical treatment. I have read and understood this document, my questions have been answered, and I accept the terms stated herein.

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