HIPAA HIPAA Form HIPAA Consent to Treat (Select Appropriate Clinic) For which clinic is this form? * Storybook Pediatrics G. F. Still ADHD Clinic Date * (MM/DD/YYYY) Child's Name * Parent(s) Names * Persons (other than parents & over the age of 18 years) who have permission to obtain medical care for my children: * I (we), the legal quardians of the above named children do hereby give my(our) consent for the persons listed below to obtain medical care for my (our) children at Storybook Pediatrics. I (we) understand that by giving persons permission to take my child/children to Storybook Pediatrics for medical care, I am also giving Storybook Pediatrics permission to disclose my child's (children's) protected health information to any of the persons on this list. I also understand that by giving these persons permision to take my child (children) to Storybook Pediatrics for medical care that I am also giving these persons my permission to make medical care decisions for my child (children) during those visits. Parent or Legal Guardian Signature: * I (we) agree to this medical consent Signature * signature keyboard Clear Submit If you are human, leave this field blank.
