Consent for Medical Treatment:
I hereby authorize the healthcare providers and staff at [Clinic Name] to provide medical care and treatment to my child, including but not limited to diagnostic procedures, medical examinations, and any necessary medical treatments deemed appropriate by the medical staff. I understand that the practice of medicine is not an exact science and that no guarantees have been made to me as to the result of treatments or examinations.
Consent for Release of Medical Information:
I authorize [Clinic Name] to release any medical information necessary to process insurance claims, coordinate care, or comply with legal requirements. This information may be released to insurance companies, other healthcare providers, or other third parties as necessary for the care of my child.
Financial Responsibility:
I understand that I am financially responsible for all charges incurred for medical services provided to my child, including any co-payments, deductibles, or charges not covered by my insurance plan. I agree to pay all charges in a timely manner according to the clinic's billing policies.
Notice of Privacy Practices:
I acknowledge that I have received a copy of the Notice of Privacy Practices, which explains how my child's medical information will be used and disclosed. I understand that I have the right to review this notice and ask any questions regarding its contents.
Consent for Communication:
I consent to receive communication from [Clinic Name] via phone, email, or text message regarding appointments, test results, and other pertinent information related to my child's care. I understand that I may opt-out of such communications at any time by notifying the clinic in writing.
Acknowledgement of Policies:
I acknowledge that I have read and understand the clinic's policies regarding appointments, cancellations, and financial responsibilities. I agree to adhere to these policies as a condition of receiving care for my child.