Advanced Consent to Treat Minors

As a general rule, we require the consent of a parent or legal guardian to provide health care services to a minor child (under the age of 18 We understand that there may be times when a parent or guardian is not able to accompany a child to an appointment. However, we cannot provide care to a child who comes to our clinic alone or accompanied by an adult other than a parent or legal guardian if we cannot reach you or don't have advanced consent to provide

Signing the Advanced Consent to Treat Minors form below ensures that we can provide care to your child under these circumstances. This signed form will be kept in your child's medical record. Consent remains in effect until revoked in writing. Any member of our staff can provide

Under Washington State law, minors have the right to consent to certain health care without a parent or guardian's consent:

• If the minor is an emancipated (legally independent) or married to someone at or above age 18.
• In the event emergency care is required.
• For birth control and pregnancy-related care at any age.
• For outpatient drug and alcohol abuse treatment beginning at age 13.
• For outpatient mental health treatment beginning at age 13.
• For sexually transmitted diseases, including HIV, beginning at age 14.

While we encourage minor patients to involve a parent, guardian or other trusted adult in all aspects of health care, if a minor consents to care as allowed by law, he or she can request confidentiality. That would prohibit us from releasing this information to anyone, including a parent or guardian, without the minor's express written consent. If you have questions regarding any of this information, please contact your child's primary care provider.

Advanced Consent to Treat Minors Form

I, __________, am the parent or legal guardian of, (the minor patient), with date of birth _______ authorize and consent to routine and emergency medical treatment for my child when deemed necessary by qualified medical personnel at Greenlake Primary Care.  This authorization will be in effect until revoked in writing by me.