Medical Care Authorization/Consent for Treatment Form

Medical Care Authorization/Consent for Treatment Form
Patient Legal Name*

First NameLast Name
Patient Preferred Name
Date of Birth*

MonthDayYear
Date
Parent/Legal Guardian Name

First NameLast Name
I hereby authorize Grace Health to give me reasonable and proper medical/dental care, which may include telemedicine services, by today’s standards. I authorize direct payment of insurance benefits to Grace Health and other entities providing services ordered by Grace Health, realizing I am responsible for any unpaid balance. I authorize the release of medical information to the Centers for Medicare & Medicaid Services and its agents, to my insurance company for billing purposes, to other health care providers for continued treatment, and other entities providing services ordered by Grace Health, understanding that this may include records of treatment for substance use; mental health treatment, including psychotherapy notes; or testing, care, treatment or reporting pertaining to infection with HIV or related diseases.
Authorization for Disclosure of Medical Information:

I authorize Grace Health to disclose medical information with the following person(s)as indicated below:
Person 1

First NameLast Name
VerbalWritten
Person 2

First NameLast Name
VerbalWritten
Person 3

First NameLast Name
VerbalWritten
Person 4

First NameLast Name
VerbalWritten
I do not wish to add any additional people for disclosure of my medical information
Consent for Treatment – Minor or Legal Ward:

Legal/biological parent(s) or guardian(s) can already seek treatment for the patient.
I authorize the following person(s) (18 years or older) to seek medical care for my child or legal ward (listed as the patient above) when I am unable to do so and understand that by allowing them to seek care for the patient, this includes, but is not limited to obtaining prescriptions, consenting for immunizations, medicines, and procedures, and that all medical information, verbal and written, may be revealed and discussed with them:
Person 1

First NameLast Name
Person 2

First NameLast Name
Person 3

First NameLast Name
Person 4

First NameLast Name
I do not authorize any non-legal guardian or person(s) to consent for medical treatment for the named patient.
I understand the information being disclosed may include medications, test results and treatment plan, including treatment for mental health, substance use and testing or treatment for HIV or AIDS. Once the information is disclosed, it is not protected under federal privacy rules, so there is a possibility it may be redisclosed by the person receiving the information.
I am the patient or legal representativeParentGuardianOther
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Medical Care Authorization/Consent for Treatment Form

Authorization for Disclosure of Medical Information:

Consent for Treatment – Minor or Legal Ward: