By signing this document, you consent to the medical providers of Bay Haven Pediatrics to provide care and make recommendations they consider necessary for your child's health and well-being during the visit.

You consent to medical providers conducting medical examination, diagnostic testing, and if necessary, minor surgical procedures. You understand that Bay Haven Pediatrics staff may be tasked with carrying out the orders of medical providers.

You understand that no medical provider or the office personnel can make and will not make any guarantees about the results of any treatment or recommendation.

By signing this document, you state that you have received from Bay Haven Pediatrics a Notice of Privacy Practices as required by law under the Health Insurance Portability and Accountability Act ("HIPAA") and regulations.

You understand that if you want Bay Haven Pediatrics to share your or your child's protected health information with someone else, you will be required make that request to the front desk staff and sign a disclosure release.

We have chosen to participate in the Chesapeake Regional Information System for our patients, (CRISP), a regional health information exchange serving Maryland and DC. As permitted by law, your child's health information will be shared with this exchange in order to provide faster access, better coordination of care and assist providers and public health officials in making more informed decisions. You may "opt out" and disable access to your child's health information available through CRISP by calling 1-877-952-7477 or completing and submitting an Opt-Out form to CRISP at www.crisphealth.org. Public health reporting and Controlled Dangerous Substances information, as part of the Maryland Prescription Drug Program will still be available to providers.

251 Najoles Road, Suite E, Millersville, MD 21108 • Phone : 410.729.0690 Fax : 866.531.7815 www.bayhavenpediatrics.com

I certify that I have received the Notice of Privacy Practices.

By signing this document, you are giving Bay Haven Pediatrics permission to communicate with you using automated calls, emails, and text messaging sent to your landline, mobile device, or email address. This is an explicit "opt in" authorization to receiving these communications.

These communications may include personal health information or other private information including preventative care, test results, treatment recommendations, outstanding balances, or any other communications from the practice. Please take necessary steps to safeguard access to your communications methods.

This document must be signed by a parent or legal guardian if the patient is legally a minor under the age of 18 or mentally unable to understand and sign this document.