Parental Permission Form

PARENT PERMISSION AND MEDICAL CONSENT FORM

Child Name: Birthdate:

Social Security # Grade:

Address:

City: State: Zip:

Home Phone: Work Phone:

Parental Consent:

(I)(We), the undersigned, parent(s) of , a minor, do hereby consent to said minor participating in conducted by .

Authorization of Consent to Treatment of Minor:

(I)(We), the undersigned, parent(s) of , a minor, do hereby authorize , hereinafter "Agent", for and on behalf of the undersigned to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care which is deemed advisable by, and is to be rendered under the general or specific supervision of any physician and surgeon licensed under the provision of the Medical Practice Act, whether such diagnosis or treatment is rendered at the office of said physician or at a hospital, during all times that the Minor is in the presence of said Agent.

It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required, but is given to provide authority and power on the part of our aforesaid agent(s) to give specific consent to any and all such diagnosis, treatment, or hospital care which the aforementioned physician in the exercise of his best judgment may deem advisable, and release Agent from all damages of same.

HIPAA Release Authority. My agent shall be treated as I would be with respect to my rights regarding the use and disclosure of my child’s individually identifiable health information or other medical records. This release authority applies to any information governed by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 U.S.C. 1320d and 45 CFR 160 through 164. I authorize any physician, health care professional, dentist, health plan, hospital, clinic, laboratory, pharmacy, or other covered health care provider, any insurance company, and the Medical Information Bureau, Inc. or other health care clearinghouse that has provided treatment or services to my child, or that has paid for or is seeking payment from me for such services, to give, disclose and release to my agent, without restriction, all of my child’s individually identifiable health information and medical records regarding any past, present or future medical or mental health condition, including all information relating to the diagnosis of HIV/AIDS, sexually transmitted diseases, mental illness, and drug or alcohol abuse.

This authorization shall remain effective through the day of , 20 , unless sooner terminated in writing.

Home Phone: Work Phone:

Other phone number:

Legal Guardian: Phone:

Other Emergency Contact: Phone:

Family Doctor: Phone:

Insurance Co.: If None Please Check:

Insurance Policy Name and #:

Known Medical Conditions:

Medications?

Allergies?

Last Tetanus Immunization?

Will You Allow Blood Transfusions? (check your response) Yes No

Other Comments: