DESIGNATION OF ANOTHER PERSON TO CONSENT FOR TREATMENT OF MINOR CHILD
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.
ONLY COMPLETE BELOW TO REVOKE AUTHORIZATION
 
Written Notice to Revoke Authorization
 
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.