Child's Name

First Name

Last Name

I hereby consent for the use or disclosure of my child's protected health information (PHI) to carry out treatment, payment, or healthcare operations. This includes assignment of benefits when applicable *

Yes

No

I have received and read a copy of the Notice of Privacy Practices for Laskin Therapy Group and understand its meaning *

Yes

No

I understand that I have the right to request that this provider restrict how PHI is used or disclosed to carry out treatment, payment or healthcare operations, and that the provider is not required to accept the requested restrictions. *

Yes

No

I have the right to revoke the consent, in writing, except to the extent that the provider has taken action prior to the revocation. I understand that this authorization is voluntary. *

Yes

No

I am the child's legal guardian

Yes

No