Authorization_of_Tx

I authorize Eastchester Family Services (EFS) to provide the following Primary Care Services:

Physical / Sport Physical	Immunizations	Hearing Services
Vision Screening	Sick Visit	Lab Services

I allow EFS to file for insurance benefits as applicable to pay for the care my child will receive.

Patient confidentiality is important at EFS therefore, we ask you to provide us the following information:

Name of any other family member or party that you authorize to speak to staff, schedule appointments and/or receive personal health information concerning your child:
Name
Relation to Patient
*Any party NOT listed above will NOT be able to access any of your child’s protected health information until this authorization is updated by the parent or legal guardian.

*Photo ID will be required from anyone listed above receiving personal health information concerning the patient from EFS.
If I am unable to be reached at the primary number listed above and/or in my child’s record, EFS may leave the following information on my voicemail (check all that apply):

Appointment RemindersReferral / Test InformationFinancial Information
By signing below, I authorize EFS to provide above listed services.
Patient/Parent/Guardian Signature*

Clear
Date Signed*

MonthDayYear
Milton Brown and Associates, Inc. dba Eastchester Family Services
www.eastchesterfamilyservices.com
Should be Empty:

Authorization of Treatment