Consent To Treat

Consent To Treat and Authorization to Disclose Protected Health Information

Please complete this form so that, in the event you cannot bring your child to an appointment, a stepparent or another adult that you authorize can accompany the child and receive information about his/her care.
Name of Parent / Legal Guardian*
Name of Child*
Child's Date of Birth*

MonthDayYear
Given your input above, please review the following statement:

I, {nameOf}, the parent/legal guardian of {HB-PatientFullName} hereby authorize the individual(s) below to accompany my child to appointments at JDC Pediatrics, consent to my child's care, and sign forms relating to my child's care.
The above statement is correct
Please check here if you do not wish to add anyone to this form
Stepmother:
Name
Date of Birth

MonthDayYear
Phone
Address
Employer
Occupation
Stepfather:
Name
Date of Birth

MonthDayYear
Phone
Address
Employer
Occupation
Others authorized to bring child (OTHER THAN PARENT OR STEPPARENT):
Name*
Relationship to Child*
Name
Relationship to Child
Name
Relationship to Child
The above named individual(s) are hereby authorized to have access to my child's entire medical record. I understand that this disclosure will include information relating to AIDS or HIV infection, treatment for substance and/or alcohol abuse or dependency, and psychotherapy notes, or other information relating to mental health or psychiatric care.

This information is being disclosed to the above listed person(s) from records whose confidentiality may be protected by the Pennsylvania Confidentiality of HIV Related Information Act. My signature below authorizes the release of information protected by these Pennsylvania statues. I understand that I have no obligation whatsoever to disclose information from my child's record, and that JDC cannot withhold treatment from my child based upon my failure to execute this authorization, unless the purpose of this authorization is to disclose health information to another party based on health care that is provided solely to obtain such information. I understand that I may revoke this authorization at any time in writing, except to the extent that action based on this authorization may be subject to re-disclosure because it is no longer protected by federal privacy laws.

I fully understand the contents of this authorization and voluntarily consent to the release of the information as stated. JDC, its employees, officers and clinical staff are released from legal responsibility or liability for the release of the above information to the extent indicated and authorized herein. Finally, I understand that I am entitled to obtain a copy of this authorization from JDC upon request.
This Consent Authorization:*

Is effective until revoked by me in writingIs effective for a date range that I specifyIs effective only on a specific date that I specify
Effective From*

MonthDayYear
Effective To*

MonthDayYear
Effective On*

MonthDayYear
Signature of Parent/Legal Guardian*

Clear
Date*

MonthDayYear
Q
K
Should be Empty:

Consent To Treat and Authorization to Disclose Protected Health Information

Stepmother:

Stepfather:

Others authorized to bring child (OTHER THAN PARENT OR STEPPARENT):