I, {yourFull}, am the parent/guardian of {patientsFull}, date of birth {patientsDob}, and I hereby authorize Madison Dental to perform Medicaid provider changes on behalf of the aforementioned patient.
I acknowledge and consent to Madison Dental acting on my behalf to facilitate the necessary paperwork and communication with the relevant authorities for the purpose of updating Medicaid provider information.
I understand that this consent is granted for the sole purpose of facilitating Medicaid provider changes and does not extend to any other medical or dental procedures or decisions. Any changes made will be in accordance with the applicable laws and regulations governing Medicaid provider updates.
I authorize Madison Dental to provide and receive information related to the Medicaid provider changes on my behalf. This includes, but is not limited to, communicating with Medicaid authorities, submitting necessary documentation, and ensuring that the Medicaid account is accurately updated.
This consent is valid until further notice from me, the undersigned, and may be revoked in writing at any time. I understand that revoking this consent does not affect any actions taken prior to receiving the revocation notice.
By signing below, I acknowledge that I have read and understood the contents of this consent form, and I voluntarily grant authorization for Madison Dental to perform Medicaid provider changes on behalf of {patientsFull}.