WAIVER FOR TREATMENT SEE PAGE TWO FOR FORM We would prefer to have the patient/parent/guardian sign this form and return to us. If a verbal authorization (i.e., phone authorization) is required, please contact our office at (402) 991-5690. This form is used to: Authorize a parent or legal guardian to authorize treatment of a minor child, handicapped child or adult without the presence of the parent or legal guardian. That is, it authorizes the patient to receive care alone or in the presence of another person, such as a caregiver, family member, grandparent, etc. Authorize Beyond Care Pediatrics, LLC. to provide access to the Protected Health Information of a patient by someone other than the patient or parent/legal guardian. For example, it may be used to authorize access to the patent s Protected Health Information by a step-parent, patient s fiancé, patient s grandparent, adult child s parents, etc.
WAIVER FOR TREATMENT PLACE PATIENT LABEL HERE I,, hereby give the following authorization(s) as indicated by my signature and initials in the applicable blanks below:, (DOB / / ) may obtain medical services at Beyond Care Pediatrics, LLC by its physician(s) or designees without my presence. I agree to authorize to obtain medical care (Name/Relationship) and treatment from the physician(s) or designees of Beyond Care Pediatrics, LLC for (DOB / / ) in the event I am unavailable to accompany them for treatment. I agree to authorize to obtain (Name/Relationship) access to the Protected Health Information (PHI) of my minor child, (DOB / / ). I understand by signing this authorization, I confirm I am the responsible legal party and I am able to execute this document on behalf of the patient named herein. I understand any change to this authorization must be in writing. In the event of revocation, the person executing revocation is required to notify the applicable parties (i.e., the other parent, guardian, etc.). Beyond Care Pediatrics, LLC. is not responsible to execute notification of revocation. Signature/Relationship (Patient, Parent, Guardian, etc.) Verbal Authorization The above statement has been read to the named party and agreement of the statement by the named party has been witnessed by:
CONTACT AUTHORIZATION Name: : Home Phone: Cell Phone: Please indicate your preference(s) with a check mark below for Home Phone / Cell Phone: Leave message/appt date and time Leave message/provider Name /Phone number Leave Message/lab/test/results/med changes Do not leave a message of any kind Voicemail/machine only Anyone that answers phone Only the people listed below Work Phone: Please indicate your preference(s) with a check mark below for Work Phone: Leave message/appt date and time Leave message/provider Name /Phone number Leave Message/lab/test/results/med changes Do not leave a message of any kind Email Address: Please indicate your preference with a check mark below for Email Address: Okay to e-mail appointment reminders. Do not email reminders Please indicate below anyone who is authorized to talk with Doctor/Nursing/Staff regarding your health care. NAME PHONE RELATIONSHIP I have verified all the above information and have given my consent to contact me as noted in this document. Patients/Guardians Signature: X :
RELEASE OF MEDICAL RECORDS : SS# Patient Name: Birth : Address: (Street) (State) (City) (Zip) Phone Number: I give consent to Bernard W. Douglas, MD to view and/or print my personal health information from the CHI Health EPIC System and Methodist Health Cerner System. Signature: (Patient or Legal Guardian)
AUTHORIZATION TO RELEASE HEALTHCEARE INFORMATION Patient Name: of Birth: Previous Name: Social Security #: Address: State: City: Zip: I authorize the release of my medical records from the medical office listed below: This request and authorization applies to: Healthcare information relating to the following treatment, conditions, or dates All healthcare information Other: Definition: Sexually Transmitted Disease (STD) as defined by law, RCW 70.24 et seq., includes herpes, herpes simplex, human papilloma virus, genital wart, condyloma, Chlamydia, non-specific urethritis, syphilis, VDRL, chancroid, lymphogranuloma venereuem, HIV (Human Immunodeficiency Virus), AIDS (Acquired Immunodeficiency Syndrome), and gonorrhea. Patient /Guardian Signature: :