I hereby acknowledge that I have received a copy of this office's Notice of Privacy Practices, and I acknowledge that I have been given the right to review this document prior to signing this consent. I understand that the Pediatric Ear, Nose & Throat Associates has the right to change its Notice of Privacy Practices from time to time, and that I may contact the office at any time to obtain a current copy of the Notice of Privacy Practices.

I understand that, under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my child's and my family's protected health information. I understand that this information can and will be used to: conduct, plan, and direct my child's treatment and follow up among multiple healthcare providers who may be involved in that treatment directly and indirectly; obtain payment from third-party payers; conduct normal healthcare operations such as quality assessments and physician certifications.

I understand that, in order to maintain communications with me about my child's health status and treatment, staff members from the Pediatric Ear, Nose & Throat Associates may from time to time communicate with me via electronic mail and/or conventional postal delivery by the United States Postal Service. I understand that transmissions by either channel may be subject to unauthorized and illegal interception, and I hereby hold harmless the Pediatric Ear, Nose & Throat Associates and its staff members, individually and collectively, for any damage or liability should such interception occur.

I understand that I may request in writing that the Pediatric Ear, Nose & Throat Associates should restrict how my private health information is used or disclosed to carry out treatment, payment, or health care operations. I also understand that the Pediatric Ear, Nose & Throat Associates is not required to agree to my requested restrictions, but, if agreement is verified in writing, then the Pediatric Ear, Nose & Throat Associates are bound to abide by such restrictions.

I understand that I may revoke this consent in writing at any time, except to the extent that Pediatric Ear, Nose & Throat Associates has already taken action relying on this consent. 





printed name and relation to child



child's name






Thank you for taking the time to read and sign this form. By federal law, this consent form must be a part of your child’s record. Please PRINT IT, SIGN IT, AND BRING IT with you to your child's next visit or FAX it to us at 860-232-2750. We are looking forward to seeing you soon.



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We attempted to obtain signed acknowledgement of receipt of our Notice of Privacy Practices and a signed Parent Consent Form, but these could not be obtained because:

o Parent(s) refused to sign
o Communication barriers prohibited obtaining the acknowledgement and consent
o An emergency situation prevented us from obtaining acknowledgement and consent
o Other -- Specify:

Certified by: ____________________________ Date: _________________