Patient Consent for Treatment of Minor - Release Info to Others

SHALOM HEALTH CARE CENTER, INC.

PROVIDING QUALITY HEALTH CARE THAT IS PATIENT-CENTERED, AFFORDABLE AND ACCESSIBLE FOR ALL IN OUR COMMUNITY.
PATIENT CONSENT FOR TREATMENT OF MINORS AND/OR RELEASE OF INFORMATION TO OTHERS
Patient Name
Date of Birth

MonthDayYear
Shalom Account Number
Release of Information to Other Persons

I authorize the release of my medical records, claims information, and payment history to thefollowing:
Spouse:
Children Age 18 & Older:
Other:
Do not release my medical records, claims information, and payment history
Authorization for Another Person to Consent to Medical Treatment

I hereby authorize the following adult:
Name
Telephone Number
Address
City
State
Zip Code

I do not authorize anyone else to consent to medical treatment.
All decisions indicated above will remain in effect until terminated by me in writing.
Signature of Patient or Parent/Legal Guardian*

Clear
Date

MonthDayYear

3400 Lafayette Road, Suite 200 • Indianapolis, IN 4622
5750 West 56th St. Indianapolis, IN 46254
PHONE: 317-291-7422 • CONFIDENTIAL MEDICAL FAX: 317-291-4912

The Center receives federal funding from Department of Health and Human Services (HHS) and has Federal Public Health Service (PHS) deemed status with respect to certain health or health-related claims, including medical malpractice claims, for itself and its covered individuals.
Should be Empty:

SHALOM HEALTH CARE CENTER, INC.

PATIENT CONSENT FOR TREATMENT OF MINORS AND/OR RELEASE OF INFORMATION TO OTHERS

The Center receives federal funding from Department of Health and Human Services (HHS) and has Federal Public Health Service (PHS) deemed status with respect to certain health or health-related claims, including medical malpractice claims, for itself and its covered individuals.