HEIGHTS PEDIATRICS, P.C.
CONSENT TO TREAT
PARENT/GUARDIAN PRE-AUTHORIZATION TO PROVIDE
MEDICAL CARE TO AN UNACCOMPANIED PATIENT
In order to provide the best medical care for your child(ren), we recognize there are times when you are unable to attend your child(ren)’s appointment. For your convenience, we provide this authorization to allow medical care for your child(ren) in your absence. Please review the information below. Initial the section(s) that are applicable, sign and return this form to our office PRIOR TO YOUR CHILD(REN)’S APPOINTMENT should you wish to authorize treatment without a parent/guardian being present. This form has no expiration date and any changes must be made in writing.
c CONSENT TO PERMIT CERTAIN INDIVIDUALS TO ACCOMPANY CHILD(REN) FOR TREAMENT:
I, _______________________________________, hereby authorize the following individual(s) to accompany my child(ren) to Heights Pediatrics, P.C. for the provision of medical services, and to view or discuss my child(ren)’s Protected Health Information (PHI). Name(s) of step-parent, grandparent, nanny/au pair/babysitter/other and relationship to child(ren).
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These individuals are able to authorize procedures such as (check authorized categories): c Immunizations c Lab Orders c X-rays c In House Treatments
c ONLY PARENT/GUARDIAN MAY ACCOMPANY CHILD(REN) FOR TREAMENT TO HEIGHTS PEDIATRICS, P.C.:
I, _______________________________________, DO NOT authorize anyone other than the child(ren)’s father, mother, and/or guardian to accompany my child(ren) to Heights Pediatrics, P.C. for the provision of medical services,
c CONSENT TO TREAT UNACCOMPANIED MINOR AT HEIGHTS PEDIATRICS, P.C.:
I, _______________________________________, request and authorize Heights Pediatrics, P.C. and its personnel to deliver medical care, this also includes routine immunizations, in house lab work, and in house treatments, to my MINOR CHILD(REN) listed below.
Minor(s) Name(s)/Dates of Birth:
Please print all information:
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Last name, First name Date of Birth
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Last name, First name Date of Birth
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Last name, First name Date of Birth
I/we may be reached at the following telephone numbers during my child(ren)’s appointment.
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Parent/Guardian/s Name Best number to be reached Alternate number
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Parent/Guardian/s Name Best number to be reached Alternate number
- I have received a paper copy of the Privacy Practices Notice (HIPAA)and Financial Policy
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PRINT NAME RELATIONSHIP SIGNATURE DAT
Please advise if there are parent/custodial relationships our office needs to be aware of. Thank you.