Authorization_of_Tx

Authorization of Treatment
Patient Information
Today's Date*

MonthDayYear
School*
Patient Name*
Date of Birth*

MonthDayYear
MaleFemaleOther / Unknown
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Package/Type*
Insurance Policy ID*
Parent / Guardian Details

For students 17 and under.
Parent / Guardian Name*
Phone Number*
Format: (000) 000-0000.
Email*
example@example.com
Privacy Disclosure

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

Clear
Date Signed*

MonthDayYear
Notice of Privacy Practices and Patient Consent for Use and Disclosure of Protected Health Information
I understand that under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain Patient Rights regarding my protected health information.

I understand that Eastchester Family Services (EFS) may use or disclose my protected health information for treatment, payment or health care operations, which means providing health care to me, the patient, handling billing and payment, and taking care of other health care operations. Unless required by law, there will be no other uses and disclosures of this information without my authorization.

EFS has a detailed document called the “Notice of Privacy Practices". It contains a more complete description of your rights to privacy and how we may use and disclose protected health information.

I understand that I have the right to read the "Notice of Privacy Practices" before signing this agreement. If I ask, EFS will provide me with the most current "Notice of Privacy Practices.”

My signature below indicates that I have been given the chance to review such copy of the "Notice of Privacy Practices. " My signature means that I agree to allow EFS to use and disclose my protected health information to carry out treatment, payment, and health care operations. I have the right to revoke this consent in writing at any time, except to the extent that EFS has taken action relying on consent.
Signature of Patient or Parent / Legal Guardian*

Clear
Relationship (if not patient)*
Date*

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

Authorization of Treatment

Patient Information

Parent / Guardian Details

Privacy Disclosure

Notice of Privacy Practices and Patient Consent for Use and Disclosure of Protected Health Information