Healthcare TCC Application Under 18

Healthcare TCC Application — Under 18

Patient Information

Patient Name:

Date of Birth:    Gender:

Parent / Legal Guardian Information

Emergency Contact

Insurance Information

Medical History

TCC Program Consent and Application Statement

I, the undersigned parent or legal guardian, request enrollment of the minor named above into the Transitional Care Clinic (TCC) program. I understand that the TCC provides coordinated medical, behavioral health, and supportive services intended to assist transition and continuity of care following an inpatient or emergency encounter. By signing, I authorize TCC clinicians and authorized staff to provide assessment, diagnosis, treatment, counseling, referral and follow-up services appropriate to the minor's needs.

I acknowledge that reasonable risks and side effects may be associated with treatments provided and that no guarantee of specific outcome has been offered. I have had the opportunity to ask questions about the nature, purpose, expected benefits and risks of recommended services and these questions have been answered to my satisfaction.

Treatment Consent: I authorize provision of medical and behavioral health care by TCC providers and delegated staff as clinically indicated for the minor while enrolled in the program.

Assent by Minor (where appropriate): Assent obtained from the minor when age-appropriate and clinically feasible. Minor's willingness to participate will be considered in care planning.

Authorization to Release and Exchange Health Information

I authorize the TCC and its contracted providers to obtain and disclose protected health information (PHI) about the minor, including but not limited to medical records, medication lists, behavioral health records, and discharge summaries, to facilitate coordination of care among hospitals, primary care providers, specialists, schools, social services and other identified caregivers. This authorization is limited to information reasonably necessary for the purposes of treatment, referral, care coordination and payment.

Release Records: I authorize release and exchange of PHI as described above.

Privacy, Messaging and HIPAA Acknowledgment

I acknowledge that I have received or been offered the TCC Notice of Privacy Practices describing how protected health information may be used and disclosed and my rights under applicable privacy laws. I understand that reasonable efforts will be made to protect PHI.

Permitted Communications: I permit clinic staff to leave appointment, care coordination, and clinical messages regarding the minor at the phone numbers or email provided.

Duration, Revocation and Expiration

This authorization is effective on the date signed and will remain in effect until the earlier of: (a) written revocation by the undersigned, delivered to the TCC; or (b) the authorization expiration date entered below. Revocation will not affect disclosures made in reliance upon this authorization prior to receipt of a revocation.

Authorization Expiration Date:

Certification and Signature (Parent or Legal Guardian)

By signing below, I certify that I am the parent or legal guardian of the minor named above and that I have the legal authority to consent to the minor's enrollment in the TCC program and to the disclosures described herein. I certify that the information provided on this application is true and accurate to the best of my knowledge. I understand that I may withdraw this authorization in writing at any time except to the extent that action has already been taken in reliance on this authorization.

Optional — Minor Assent (If Applicable)

The minor may sign below to indicate they understand the nature of participation and assent to receive services when age-appropriate. This signature does not substitute for parental consent where parental or guardian authorization is required.

Additional Information or Notes for Intake (clinical observations, social needs, school concerns):

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