Adult Consent and Authorizations

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Consent: In connection with the medical services that I am receiving from Interlachen Pediatrics, P.A. and its medical staff, I, in accordance with Florida Statute 1014.06, hereby consent to Interlachen Pediatrics, P.A. and their respective agents to provide or arrange to provide health care services or prescribe medicinal drugs to the patient named below. This consent is valid from the date executed until revoked in writing by the patient.

Interlachen Pediatrics, P.A. may call my primary phone number or other alternate phone number I have provided. If I am unavailable,Interlachen Pediatrics, P.A. may leave a message on voice mail in reference to any items that assist the practice in carrying out treatment, payment and healthcare operations (TPO), such as appointment reminders, insurance items and any calls pertaining clinical care, including laboratory and radiology results among others a per the Privacy Policy. In addition, Interlachen Pediatrics, P.A. may contact me via text message at my mobile phone number I have provided to send me appointment reminders for my child, notify me of health reminders, office

information and other items that assist in carrying out TPO.

Interlachen Pediatrics, P.A. may mail to my primary address, other alternate address I have provided, or the secure patient portal, any items that assist the practice in carrying out TPO, such as appointment reminder cards, patient statements, school immunization and or physical forms; all correspondence mailed to a physical address will be marked “Personal and Confidential”.

Interlachen Pediatrics, P.A. may e-mail my personal e-mail, or other alternate e-mail I have provided, any items that assist the practice in
carrying out TPO.

Interlachen Pediatrics, P.A. may contact me through the secure patient portal to discuss treatment, payment and health care operations (TPO) including, but not limited to; laboratory and imaging results, immunization history, medication refills, insurance information and billing.

Medical Release: I authorize any holder of medical or other documentation about me to release to Interlachen Pediatrics, P.A., independent laboratories and insurance carriers any information needed for claims processing and payments. I permit a copy of this authorization to be used in place of the original.
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I authorize Interlachen Pediatrics to discuss or release medical information with the following person:* This field is required.
First Name
Last Name
3
I authorize Interlachen Pediatrics to discuss or release medical information with the following person:
First Name
Last Name
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Healthcare Proxy: I authorize Interlachen Pediatrics to provide access to my confidential medical records through the secure patient portal to the following person to act a healthcare proxy on my behalf. I understand this access can be revoked at any time verbally or in writing.
First Name
Last Name
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Healthcare Proxy: I authorize Interlachen Pediatrics to provide access to my confidential medical records through the secure patient portal to the following person to act a healthcare proxy on my behalf. I understand this access can be revoked at any time verbally or in writing.
First Name
Last Name
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Signature* This field is required.
Clear
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Date* This field is required.
Date
Month
Day
Year
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Patient's NamePlease type your full name
First Name
Last Name
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Cell Phone Number* This field is required.
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Email Address* This field is required.
example@example.com
Should be Empty: