Healthcare Pediatrics Document

PEDIATRIC PATIENT INTAKE, CONSENT & AUTHORIZATION

Patient and Guardian Information

Patient Name:    Date of Birth:

Gender: Male   Female   Other/Prefer not to say

Insurance and Billing

Medical History & Current Health

Immunization Status: Up to date   Not up to date   Unknown

Consent for Treatment and Procedures

I, the undersigned parent or legal guardian, hereby authorize the pediatric practice, its physicians, nurses and allied health personnel to provide medical examination, diagnostic procedures, routine immunizations, administration of medications, and treatment as may be medically necessary for the patient named above. I understand that all procedures will be explained and that I may ask questions regarding the nature and purpose of the proposed care.

I acknowledge the risks inherent in medical treatment, including but not limited to allergic reaction to medications or vaccines, unforeseen complications, or adverse reactions. The provider has explained the benefits and risks of recommended treatments and I consent to such care as is necessary in their professional judgment.

I understand that I may withdraw consent for non-emergency treatment at any time, except where treatment is necessary to prevent imminent harm or is required by law. Withdrawal should be communicated in writing when possible.

I authorize the provider to obtain and review the patient's past medical records, immunization records, and to communicate with other healthcare providers as needed for continuity of care.

Consent for Vaccinations: I authorize routine immunizations as recommended by the provider.    I decline immunizations at this time.

Authorization to Release Protected Health Information (PHI)

I authorize the release of protected health information related to the patient named above to the following persons or entities for treatment, billing, and care coordination purposes: (list names and relationship or organization).

This authorization includes disclosure of immunization records, diagnostic test results, treatment summaries, and any other information necessary for the purpose stated above. I understand that this authorization is voluntary and that I may revoke it in writing at any time, except to the extent that action has already been taken in reliance on it.

Financial Responsibility

I understand that I am financially responsible for services provided to the patient and that the practice will bill the insurance company as a courtesy. I agree to pay any co-payments, deductibles, or amounts not covered by insurance. If collection action is necessary, I will be responsible for additional fees.

Acknowledgments

Acknowledgment of Privacy Practices: By signing below I acknowledge that I have received or 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, and I understand my rights regarding that information.

Truthful Information: I certify that the information provided on this form is accurate to the best of my knowledge. I will promptly report changes in insurance, contact information, or medical condition.

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