CONSENT FOR TREATMENT: UNEMANCIPATED MINOR

Coeur d'Alene 700 W. Ironwood Drive, Suite 155 Coeur d'Alene, ID 83814 (208) 667-0585 Post Falls 1300 E. Mullan Avenue, Suite 1000 Post Falls, ID 83854 (208) 777-1330

Coeur d'Alene PediatricsHayden9095 N. Hess Street Hayden, ID 83835 Adolescent Medicine Pediatrics

Duane Craddock, MD Jonathan Jerkins, MD Charlotte Weeda, MD Sandra Kibler, FNP Emmalee Gerstenberger, DNP Cheri Savage, MD Alicia Sauter, MD Britney Holden, PNP Nichole Buynak, DO Heidi Cooper, P.N.P. Christy Sutton, FNP. Morgan Melton PNP

Minor Patient

Birthdate

Date

1. Authority: I am the parent, guardian or other person legally authorized by Idaho law to consent for health care services for the Minor Patient pursuant to Idaho Code § 32-1015.

2.Consent for Treatment: I voluntarily consent to and authorize Coeur d'Alene Pediatrics and its employed or affiliated physicians, practitioners, and staff to render the following health care services to the Minor Patient:

General Consent: Medical evaluation, diagnosis and treatment; diagnostic services including lab tests or radiology procedures; prescription and administration of medications; counseling; and any other healthcare services as defined in I.C. § 32-1015 deemed reasonably necessary and appropriate by the treating Provider. This consent shall constitute a "blanket consent" within the meaning of I.C. § 32-1015(4a) and no further consent is required to authorize such health care services.

Please detail the specific care or date range for which consent is given:

3.Authorization of Other Caregivers: I hereby consent to Coeur d'Alene Pediatrics to allow the below caregiver(s) to make appointments for my child and bring my child to appointments for the health care services authorized above. I also authorize this individual to perform these specified tasks.

Caregivers Name

Relationship to Child

Phone Number

Format: (000) 000-0000.

I authorize this caregiver for the following:

Would you like to authorize additional caregivers?

Caregivers Name

Relationship to Child

Phone Number

Format: (000) 000-0000.

I authorize this caregiver for the following:

Would you like to authorize additional caregivers?

Caregivers Name

Relationship to Child

Phone Number

Format: (000) 000-0000.

I authorize this caregiver for the following:

4.Information. The Provider has explained the nature of the proposed heath care services, alternatives, and their related risks and benefits, or I have waived my right to receive such information. I have had the opportunity to ask questions and all my questions have been answered to my satisfaction or I have declined to ask such questions. IfI require additional information concerning the health care services, I will contact Coeur d'Alene Pediatrics or the Provider to discuss such services. I understand that the practice of medicine is not an exact science and no promises or guarantees have been made nor can they be made to me concerning the outcome of the health care services.

5.Financial Responsibility. I agree that I am ultimately responsible for payment for the health care services rendered to the Minor Patient and agree to comply with Coeur d'Alene Pediatrics Financial Policies. I will promptly pay any co- payments, deductibles, or other amounts not covered by applicable insurance or hird-party payor program. To the extent allowed by law, I will remain responsible for any amount not paid by any third-party payor for health care services, including but not limited to costs relating to infectious, contagious or communicable diseases within the meaning of I.C. § 39-3801. If the Minor Patient's account becomes delinquent, I agree to pay interest and fees according to GROUP's Financial Policies, including but not limited to reasonable costs of collection, CO llection agency fees, attorneys' fees, and court costs.

I have read, understand, and agree to the foregoing, and I understand and acknowledge that Coeur d'Alene Pediatrics and/or its Providers will render health care services in reliance on this consent.

Full Legal Name

Relationship to Minor Patient

Phone Number

Format: (000) 000-0000.

Today's Date

Date

Signature