I am the parent or legal guardian of “Minor Child” above, who is not emancipated and under age 18. By signing this form, I authorize (“Designated Adult”) to consent to or refuse any dental care or treatment for "Minor Child" that is recommended by The Center for Pediatric Dental Care LLC dental provider. I understand that my authorization is given prior to any dental treatment or recommendation. However, this authorization empowers "Designated Adult" with authority to exercise his/her best judgment upon the advice of the The Center for Pediatric Dental Care LLC dental provider, and consent to or refuse any dental care or treatment for "Minor Child."

 

I retain the responsibility for all charges by The Center for Pediatric Dental Care LLC resulting from "Designated Adult’s" consent. I release The Center for Pediatric Dental Care LLC, providers, and staff from any liability arising from this form and "Designated Adult’s" consent to or refusal of treatment for Minor Child.

 

I understand that the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and other applicable state laws govern the disclosure of Protected Health Information (PHI). I authorize The Center for Pediatric Dental Care LLC to disclose Minor Child’s PHI to "Designated Adult".

 

My authorization is effective until Minor Child reaches age 18, or until I revoke my authorization in writing.

 

 

I, "Legal Guardian," am the original maker of this designation form. Upon signing this Written Notice below, I no longer authorized the "Designated Adult" above to consent to or refuse any dental care or treatment for "Minor Child" above.