Please PRINT and complete this form. BRING it to your child's first visit

or FAX it to 860-232-2750.   Thank You.

 

 

Authorization To Treat Your Child

 

Patient:_________________________________________Date of Birth:___________

I, the undersigned, do hereby authorize Howard G. Smith, M.D. and other staff of Pediatric Ear, Nose & Throat Associates, P.C. to provide treatment for the above minor child.

I also authorize the release of all medical records belonging to the above patient especially those relating to the patient’s past and present ear, nose, throat, respiratory and general head and neck problems, illnesses, and treatment thereof, to other medical professionals involved in my child’s care.

I understand that, in order to maintain communications with me about my child’s health status and treatment, staff members from Pediatric Ear, Nose & Throat Associates, P.C. may from time to time communicate with me via electronic mail, electronic voice messaging, and postal delivery. I understand that these transmissions may be subject to unauthorized and illegal interception. I hereby hold harmless the Pediatric Ear, Nose & Throat Associates, P.C. and its staff members, individually and collectively, for any damage or liability should such interception occur.

I furthermore authorize Dr. Smith and the staff of Pediatric Ear, Nose & Throat Associates, P.C. to submit on my and my child’s behalf claims for reimbursement to the appropriate insurance company or managed care organization.

Signed:______________________________________________________

Relation to Patient:________________________Date:________________

 

Please PRINT and complete this form.

BRING it to your child's first visit or FAX it to 860-232-2750.

Thank You.

 

 

 

Next: Medical Records Request