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Pediatrics Medical Release Form Template

Streamline Consent for Pediatric Care with Ease

When it comes to your child's healthcare, waiting for paperwork can be stressful. This pediatric medical release form template helps you swiftly secure parents' consent, ensuring timely treatment for minors. It offers clarity in the consent process, protects your practice legally, facilitates better communication between parents and healthcare providers, and assures compliance with medical standards. Access this template to support your pediatric care today.

Use this Template (FREE) Live Preview
Child full legal name
Child date of birth
Child mailing address
Your full legal name
Primary phone
Email
Relationship to child
Mother
Father
Legal guardian
Foster parent
Grandparent
Other
Please Specify:
Recipient name or organization
Recipient email (optional)
Recipient fax (optional)
Recipient type
Doctor/clinic
Hospital/health system
School
Daycare/camp
Therapist/counselor
Insurance company
Self (parent/guardian)
Other
Please Specify:
What information should be released?
All records for the dates specified below
Immunization record only
Only the specific types selected below
Select record types to release (if applicable)
Please Specify:
Record date range start (leave blank if not restricted)
Record date range end (leave blank if not restricted)
Sensitive categories (select any that apply)
HIV/AIDS-related information
Mental/behavioral health information
Genetic testing information
Substance use treatment records
Sexual and reproductive health information
None of the above
Purpose of disclosure
Continuity of care or second opinion
School/daycare/camp requirement
Insurance/benefits
Personal use
Legal purposes
Other
Please Specify:
Expiration date (if selected above)
Authorization expiration
One-time use for this request
On the date specified below
6 months from signature date
1 year from signature date
Until revoked in writing (if allowed by law)
I authorize the pediatric practice to release the selected information to the recipient named above.
Yes
No
Please confirm the statements that you acknowledge
I understand this authorization is voluntary and may be revoked in writing at any time, except to the extent action has already been taken.
I understand that information disclosed may be re-disclosed by the recipient and may no longer be protected by HIPAA.
If I selected any sensitive categories above, I authorize their release.
I certify that I am the parent or legal guardian and have authority to make this request.
I understand reasonable copying or delivery fees may apply.
Type your full legal name to sign
Date signed
{"name":"Child full legal name", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Child full legal name, Child date of birth, Child mailing address","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
Paper art illustration representing a pediatrics medical release form template for an article on FormCreatorAI

When to use this form

Use this form when your child may need medical care and you cannot be there. It covers school days, field trips, sports camps, church retreats, babysitters, or stays with grandparents. You authorize a trusted adult to talk with doctors, consent to treatment, and access needed records. For routine sharing of records, you can attach a HIPAA Authorization form. If the caregiver will also make everyday decisions, pair it with a Caregiver consent form. When a child takes medication at school or camp, include dosing instructions and a Prescription authorization form. The result: faster care in an emergency, fewer calls back to you, and clear guidance for clinics, urgent care, or the ER.

Must Ask Pediatrics Medical Release Questions

  1. Who is authorized to consent to treatment, and what is their relationship to the child?

    Full names, relationship, phone, and a backup contact help staff verify authority fast. Clear identity prevents delays or refusal of care.

  2. What care do you authorize, and what limits apply?

    List what is allowed, such as exams, imaging, stitches, anesthesia, or hospitalization. Naming limits or exclusions sets expectations and protects your wishes.

  3. What are the child's allergies, conditions, and current medications with dosing?

    Clinicians use this to avoid reactions and interactions. Include over-the-counter meds and devices like inhalers or EpiPens.

  4. What are the child's pediatrician contact details and insurance information?

    With doctor info, policy numbers, and group IDs, providers can coordinate care and billing quickly. If a procedure needs insurer approval, note it and attach a Prior authorization form.

  5. May providers share and obtain the child's medical information for this consent, and when does it expire?

    Privacy laws require explicit permission to exchange records, so state the purpose and the parties. An expiration date and how to revoke consent keep the authorization precise and compliant.

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