Huron Ophthalmology - Minor Policy Form

Huron Ophthalmology, PC

Permission to Treat a Minor without a Parent/Guardian Present

Huron Ophthalmology must receive permission from a child’s parent or legal guardian before providing an eye exam or any treatment from injury or illness that if non-life threatening. This form gives us legal permission to examine and treat your child in case you cannot accompany him/her to the clinic for their visit. If the party accompanying your child (baby-sitter, friend, relative, etc.) does not present this information, the clinic will attempt to contact you to request permission to examine and treat your child.

Note:

Minors may not receive an exam or treatment without a parent/legal guardian, unless the parent/legal guardian gives their consent for another adult party, must be 18 years of age, to accompany the minor patient for their appointment.

The adult party accompanying the minor will be responsible for making any medical decisions when/if there is an emergency during the minor’s appointment.

A new “Permission to Treat a Minor without a Parent/Guardian Present” form is required for each visit that a minor will be seen without his/her parent/legal guardian

Every three years a parent/legal guardian must accompany the minor patient for their appointment, in order for Huron Ophthalmology to ensure appropriate insurance/billing information, signature of HIPAA forms, etc.

Patient’s Name: _________________________________________________

Patient’s Date of Birth: ________________________ Today’s Date: __________________

I grant _______________________________ (an adult into whose care, the minor has been entrusted), to arrange for and authorize routine eye exam and/or treatment at Huron Ophthalmology on ______________(date).

______ Please initial here if you are authorizing the minor to seek and consent to an exam and treatment without parent/legal guardian present. We/I acknowledge that we are responsible for all reasonable charges in connection with the exam, care, and treatment rendered.

Please send the insurance card and co-pay (if applicable) to the appointment.

Name of Health Insurance Carrier:


Group Number:


Subscriber ID:


Vision Insurance Carrier:


Subscriber ID:



In case of an emergency, I can be reached at:

Work Phone Number:


Cell Phone Number:



Signature: _____________________________________________ Date: ______________


Relation to patient (documentation may be requested): _________________________________


 

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