Patient Permission Form

I have agreed to allow certain individuals to participate in the discussion and decisions to my child/children's medical care. As well to grant permission for the individuals to be able to act on my behave in case I'm not present at doctor's appointments. Therefore, I hereby give my permission for Atlanta Pediatric Partners, PC to disclose my personal medical information to the following individuals:
Name*
Relationship to Parent*
Name
Relationship to Parent
Conditions for Disclosure (Check item(s) that apply):
Conditions for Disclosure*

The practice may disclose my personal health information to the individual(s) above in discussions during my presence and when I am not physically present,including disclosures by telephone, fax, email or regular mail.Other conditions of disclosures
I understand that his consent may be revoked at any time by written notice to the practice.
Patient's Name*
Date of Birth*

MonthDayYear
Date
Parent's Name*
Parent's Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: