Greater Rochester Orthopedics - Pre-authorization to Treat Minors Consent Form

Pre-authorization to Treat Minors Consent Form

Greater Rochester Orthopedics
It may be convenient to have prior authorization in place so that medical care and treatment may be delivered directly to minors if a parent or legal guardian cannot be present prior to the provision of medical care and treatment by the medical professionals at Greater Rochester Orthopaedics, P.C. (the "Group"). Please review the following authorization for treatment and complete the information if you want to authorize such treatment for your minor child in advance.
AUTHORIZATION:

I (we) have the legal right to preauthorize the Group to deliver medical care and treatment to my ( our) child. I (we) request and authorize the Group and its medical professionals to deliver medical care and treatment to my (our) child listed below:
Child's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
I confirm that the individual(s) listed below are authorized to act as my child's proxy in my absence:
Name/Relationship to patient
Be advised that patient protected health information may be shared with the proxy to whom the right to consent has been delegated to facilitate informed decision making.

LIMITATIONS:
Identify and specify any limitations on the kinds of medical care and services for which this authorization is given. If none, state "none."*
Identify and specify any limitations on the time frame for which this authorization is given. If none, state "none."*
I understand that this Preauthorization may be revoked at any time in writing to Group.

CONTACT INFORMATION:

If the nature of the medical care and treatment is not routine, please try to contact me (us) regarding the health care of my (our) child at the following number( s). If you are unable for any reason to contact me, you may rely on the proxy decisionmaker for consent.
Parent 1
Parent's Name

First NameLast Name
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Parent 2
Parent's Name

First NameLast Name
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
In Witness Whereof, we have signed this Preauthorization as of the date below.
Today's Date*

MonthDayYear
Date
Parent or Legal Guardian 1
Draw Your Signature

Clear
Parent or Legal Guardian 2
Draw Your Signature

Clear
Should be Empty:

Pre-authorization to Treat Minors Consent Form