healthy kids care

at sunrise

3196 S. MARYLAND PKWY STE 411 LAS VEGAS, NV 89109

P : (102) 444-1685

F : (102) 444-1916

Email : info@healthykidscarelv.org

Parent / Guardian Consent for Use and Disclosure of Protected Health Information (PHI) Preview

Patient Name

Date of Birth

Enter Your legal Name

am the parent or legal guardian of the patient listed above. I authorize Healthy Kids Care (HKC) to use and share my child’s protected health information (PHI) for the purposes of treatment, payment, and healthcare operations. These activities include providing medical care, billing insurance, and managing office operations.

Checkboxes

I understand that the Notice of Privacy Practices explains in more detail how my child’s health information may be used and disclosed. I have the right to review this notice before signing, and I may request a copy from the office at any time.

Checkboxes (copy)

I understand that I may revoke this consent in writing at any time, except for information already disclosed based on this authorization. If I choose not to sign this form, Healthy Kids Care (HKC) may decline to provide treatment to my child.

Communication Authorization

Phone Call / Voicemail (messages may include appointment reminders or limited medical information)
Text Message
Email

Please indicate how our office may contact you regarding your child's care:

‍‍ Authorized Adults for Appointments

Please list adults who are allowed to bring the patient to appointments and make routine medical decisions if the parent/guardian is not present.

Full Name

Relationship To Patient

Phone #

Full Name

Relationship To Patient

Phone #

Full Name

Relationship To Patient

Phone #

Patient ‍‍ Phone

Checkboxes

No one other than the parent/legal guardian listed above may bring the child to appointments.

Parent/Guardian Name

Relationship to patient

Date

Signature

Clear Signature