Emergency Contact Information (A local person other than Parents or Guarantor)
HIPAA Disclosure (People other than parents/guardians)
(Please provide all the insurances for the child. Not providing all the insurance information will result in the patient being discharged from the practice)
Who is authorized to bring the child(ren) for a visit and make medical decisions on their behalf?
CONSENT FOR EXAMINATION, MEDICAL TREATMENT AND CONDITIONS OF EXAMINATION
INFORMATION CONCERNING FILING A CLAIM WITH YOUR INSURANCE COMPANY
AUTHORIZATION TO FILE INSURANCE CLAIMS, TO RELEASE MEDICAL INFORMATION AND ASSIGNMENT OF BENEFITS
AGREEMENT AS TO CO-PAYMENTS, NON-COVERED OR NON-PAID SERVICES AND GUARANTEE OF PAYMENT
Authorization for Request of Medical Records
I hereby authorize the release of information from the medical record of:
Please Release Information To:
Preferred Medical Group: Centralized Fax: (334) 664-0466
Informed Consent for Release of Confidential Information.
I understand that I may revoke this consent in writing at any time except to the extent action has been taken.
I understand that this consent will expire 90 days after the date of my signature unless otherwise specified.
I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer be protected by Federal Privacy Regulations.
This field is for validation purposes and should be left unchanged.