There may be times where you are unable to bring your child in for a visit. This form allows you to designate other family members, caretaker, or other person to bring your child in for a visit. We will not be able to see your child if they are brought in by someone that is not on a signed consent form or the initial intake paperwork.
Because of the ever changing insurance policies and more plans transferring costs to the policy holder with high deductibles and large copays, a credit card must be kept on file. A credit card authorization form must be kept on file for all patients in the practice.
A signed release is required to be on file anytime a request is made for copies of a patient record. We cannot release records to anyone until a release is signed.