This form will allow patients to authorize copies of their medical information to be released to person/ facility named.
This form will allow you to designate an individual to make health care decisions on your behalf in the event you become unable to make or communicate such decisions yourself.
Patients between 16-18 years of age may be seen without a parent/legal guardian for follow-up visit. The parent/legal guardian must complete a Permission to Treat a Minor Form prior to the scheduled appointment. Additionally, the parent/legal guardian must also agree to be contacted by phone during the exam by the provider. If permission from a parent/legal guardian cannot be obtained, the child cannot be seen.
Any child under the age of 18 years old cannot be seen by a doctor without written consent from a parent/legal guardian or without an adult present. If the minor is under 16 years of age, he/she must be accompanied by an adult. If the minor arrives with someone other than a parent/legal guardian, we must have written permission from the parent/legal guardian that this person has been appointed by you to act on your behalf. Prior to the scheduled appointment, the parent/legal guardian must complete a Permission to Accompany a Minor Form. This accompanying individual must have a photo ID on them at time of the minor’s appointment.
This notice describes how medical information about patients may be used and disclosed and how patients can get this information.
This form is used to revoke or to confirm revocation of a previously authorized disclosure.
This completed form must be returned 1 week prior to your scheduled appointment.