FAMILY TREE CLINIC PARENT/GUARDIAN CONSENT FORM

Adolescents under age 18 must have a signed parent/guardian consent form on file to receive some general medical services. According to state law, parental consent is not required for pregnancy and contraceptive services, chemical abuse assessment and counseling, or diagnosis/testing and treatment of sexually transmitted infections. * Note: A signed parent consent form lasts until the child turns 18, unless withdrawn. If the consent form is not returned, anyone under 18 will not be able to receive general medical services, however confidential reproductive health services are available by state law.*

Patient Name (preferred): *

Birth date: *

Date

Legal name or name listed on insurance card: *

This name will be listed in our electronic health record system and will be used for prescriptions, lab orders and billing purposes only. We will not call the patient by this name, but bills will be sent to your insurance company or mailing address with this name if there are outstanding balances.

My child has my permission to receive general medical services at Family Tree Clinic.

If applicable, I give permission to bill my health insurance carrier or Medical Assistance for general medical services received. (This would also apply if you do not currently have insurance but get it later.) I have received the notice of privacy practices stating I may have access to my child’s general medical record but not to any confidential services provided as stated in the Minnesota Statute 144.241-347. I understand I will be notified in case of emergency or need for follow up medical care.

Print parent/guardian name *

Date of birth *

Date

Phone number

Relationship to patient *

Print parent/guardian name

Date of birth

Date

Phone number

Relationship to patient

Please note any additional parents or guardians here:

Parent/guardian signature *

Clear

Today's date *

Date

IMPORTANT INSURANCE INFORMATION: PLEASE FILL IN ANY/ALL OPTIONS BELOW THAT APPLY TO YOUR CHILD.

My child does not have medical insurance

My child has Medical Assistance or MN Care. PMI and/or policy #:

Policy #:

Group #:

My child has other insurance.

Name of insurance company:

Insurance Company Phone #:

Insurance Company Address:

Policy holder's name:

Policy holder's SS #:

Member ID #:

Group #:

If you have any concerns regarding this consent form, please contact the Clinic Manager at (651)645-0478.