PARENT/GUARDIAN CONSENT FOR CAREGIVERS TO OBTAIN TREATMENT

PARENT/CUSTODIAN CONSENT FOR CAREGIVERS TO OBTAIN TREATMENT
Child's Name
Child's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent/Custodian Name
Parent Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
The following individuals are authorized to seek medical testing, diagnosis, and treatment for the child named above by Frederick County Pediatrics when the child is in the custody of these individuals.

Authorized Individual(s) (If authorizing more than two individuals, please complete another form
Individual's Name
Relationship to Child
Address
Phone Number
Format: (000) 000-0000.
Individual's Name
Relationship to Child
Address
Phone Number
Format: (000) 000-0000.
By granting this authorization, I acknowledge:

I am responsible for the payment of all financial obligations incurred in providing treatment. If Frederick County Pediatrics has a credit/debit card on file, Frederick County Pediatrics is authorized to charge the card on file according to the credit/debit card authorization. Frederick County Pediatrics may share personal health information related to my child. I waive any claim against Frederick County Pediatrics related to disclosing my child's personal protected health information to the Authorized Individuals. I may revoke this authorization by contacting Frederick County Pediatrics. Revoking this authorization does not void the waiver in the last paragraph for treatment that has already occurred.
Parent Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

PARENT/CUSTODIAN CONSENT FOR CAREGIVERS TO OBTAIN TREATMENT