Patient authorizes the physicians, medical attendants, and the hospital to furnish full and complete medical information to the specified attorney at law, or to any representative or investigator from his/her firm. The form also provides that all prior authorization is cancelled.
Medical Authorization Form For Minor In Bronx
Category:
State:
Multi-State
County:
Bronx
Control #:
US-00426
Format:
Word;
Rich Text
Instant download
Description
Free preview
Form popularity
More info
Using this form, you give permission to other adults to act for you, in your absence, regarding the treatment of your child. This is a legal document.I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form: In. Patients or their representatives should complete and submit an Authorization to Release Protected Health Information (PHI) using this link. Our policy is to fulfill medical record requests within ten (10) days from the date the request is received. Usually, record requests are completed before then. This consent form should be taken with the child to the hospital or physician's office when the child is taken for treatment. Fill out the forms electronically, and email them to the secure email address listed for your child's school-based health center.