HIPAA | Storybook Pediatrics

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) 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 *

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