initial 1. Consent for Treatment I voluntarily consent to necessary medical evaluations, treatments, and procedures for the patient (Patient Name:   Name   ) at Columbus Children’s Healthcare CCH Pediatric Clinic P.C. (“CCH”). I understand no guarantees or assurances have been made regarding outcomes. This consent remains valid for all visits unless revoked. I retain the right to refuse treatment, and any special procedures will require additional consent. If the patient is a minor, I understand that a parent, legal guardian, or authorized adult must accompany and stay with the patient throughout the entire examination.

 

initial   2. Release of Information I authorize CCH to share my (or my child’s) medical record, including medical, demographic, and insurance information, with referring providers, insurance companies, or third-party payers as needed for treatment and billing purposes.

 

initial   3. Revocation of Consent This consent remains valid until revoked by me, verbally or in writing.

 

initial   4. Financial Responsibility & Payment Obligations I accept full financial responsibility for all charges, including non-covered services and reference lab fees. Payment is required in full unless covered by insurance. I am responsible for obtaining prior authorizations and insurance approvals as required. Failure to secure necessary pre-certifications does not exempt me from payment. Subject to federal and state law, I agree to pay all costs, including reasonable attorney fees, interest, delinquent charges, and expenses, if CCH has to take action to collect payment due to my non-payment.

 

initial  5. Assignment of Benefits I assign all insurance benefits directly to CCH for services rendered. CCH may apply any overpayments to outstanding balances. This assignment is irrevocable for the current course of treatment.

 

initial 6. Communication Authorization I consent to being contacted by CCH by mail, email, phone (including cell phone), automated calls, and text messages for appointment scheduling, billing, or other matters related to my account. If my contact information changes, I will promptly notify CCH.

 

initial  7. Acknowledgment of Privacy Practices I acknowledge receipt of the CCH Notice of Privacy Practices.

 

initial 8. Acknowledgment of Financial Policy I acknowledge receipt of the CCH Financial Policy.

I, (Parent/Legal Guardian) , the parent or legal guardian ofChild’s Name ,   Child’s Name and Date of Birth hereby authorize the individual(s) listed below to act as temporary guardian(s) for the purpose of bringing my child to CCH. These individuals have permission to bring my child to the clinic and consent to healthcare treatments and examinations in my absence. This authorization is valid for one year from the effective date unless otherwise specified in writing.