Non-Parent/Guardian to Accompany Patient Authorization Preview

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Authorization - Non-ParenUGuardian to Accompany Patient 

 

Periodically there may be times when you are unable to bring your child to the office for an appointment and need to rely on a family member or friend. We understand these circumstances; however, we must have a written authorization letter allowing this person to accompany your child(ren). The person bringing your child will need to present a photo identification at the time of service.

 

This authorization gives the person permission to bring your child(ren) in, speak to the doctor, authorize medication/treatment, and make general health decisions.

Agreement:

I,
,give the person(s) listed below permission to bring my child to Children's Psychiatric Services of South Texas, and to discuss and share medical information about my child. I further authorize them to see all necessary medical records and make health care decisions of a routine nature as determined at the sole discretion of the CPSOST provider.
I also give them authority to make more serious or urgent health care decisions in the event I cannot be reached or where it is of an emergency nature where there is not sufficient time to seek out my specific consent.
Child's Name
Child #1 Full Name
Date of Birth
Child #1 DOB
Add a second child?
Add a third child?

LIST INDIVIDUALS ALLOWED TO BRING CHILD(ERN)

IF ONLY PARENTS ARE ALLOWED TO BRING CHILD IN, PLEASE INDICATE 'NONE'
Name of Person (allowed to bring child):
Add a second contact?
Add a third contact?

Electronic Signature Disclosure and Consent:

Agree
By selecting the “I agree” button, I am signing this document electronically. I agree that my electronic signature is the legal equivalent of my manual/handwritten signature on this document. By selecting “I agree” using any device, means, or action, I consent to the legally binding terms and conditions of this document. I further agree that my signature on this document is as valid as if I signed the document in writing. I am also confirming that I am authorized to enter into this Agreement. If I am signing this document on behalf of a minor, I represent and warrant that I am the minor’s parent or legal guardian. I may decline to electronically sign this document and withdraw my consent to sign this document electronically by contacting the signature requestor directly, which may delay transactions. I may contact the signature requestor separately to request to sign this document on paper or to receive a paper copy of the signed document. Any fees for such paper copy will be charged then by the signature requestor. When I sign the document, I will receive a copy of this document via email.
Signers Name
Signers Date of Birth