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 With Minor In Harris
Category:
State:
Multi-State
County:
Harris
Control #:
US-00426
Format:
Word;
Rich Text
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Responsible Party: Name, Address, Home Phone Number. Birth Date, E-Mail Address.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. The minor patient using Harris Health System form 280331 (or 280331S shaded version) Disclosure and Consent for Medical and Surgical. If you have any questions or need assistance completing the Authorization, you can call (713). 970-7330. You can sign into MyChart, our online patient portal.