• PATIENT CONSENT AND AUTHORIZATION

  •  1. Consent for Treatment I voluntarily consent to necessary medical evaluations, treatments, and procedures for the patient (Patient 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.

     

       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.

     

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

     

       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.

     

      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.

     

     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.

     

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

     

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

  • SIGNATURE

    BY SIGNING BELOW, I CONFIRM THAT I HAVE READ, UNDERSTAND, AND AGREE TO THE TERMS OF THIS AUTHORIZATION. I AM A PATIENT OR LEGALLY AUTHORIZED TO SIGN ON BEHALF OF THE PATIENT.
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  • AUTHORIZED PERSON FOR MEDICAL PURPOSES

  • At Columbus Children’s Healthcare CCH Pediatric Clinic, P.C. (“CCH”), we are committed to providing the highest quality care for our pediatric patients. To ensure comprehensive medical care, we require that a parent or legal guardian be present for all well-child visits.

    Well visits are essential for monitoring your child’s growth, development, and overall health. These appointments also provide an opportunity for our physicians to:

    • Obtain accurate medical history and updates.
    • Assess developmental milestones and address any concerns.
    • Provide important health education, guidance, and preventive care recommendations.
    • Discuss vaccination schedules and any necessary screenings.

    A custodial parent or legal guardian must attend these visits to ensure that important medical information is communicated effectively and that informed decisions regarding the child’s health can be made. If a parent or guardian is unable to attend, we ask that you contact our office in advance to discuss alternative arrangements.

    Your child’s health and well-being are our top priority, and your participation in their care is vital. In the event that you cannot be present for a sick visit, please complete the following section to provide consent for treatment in your absence.

  • Authorized Persons for Medical Purposes

  • I,  , the parent or legal guardian of ,   Pick a Date 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. 

  • SIGNATURE

    BY SIGNING BELOW, I CONFIRM THAT I HAVE READ, UNDERSTAND, AND AGREE TO THE TERMS OF THIS AUTHORIZATION. I AM A PATIENT OR LEGALLY AUTHORIZED TO SIGN ON BEHALF OF THE PATIENT.
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