Alaska Bleeding Disorder Clinics

 Consent for Care and Treatment of a Minor Patient

TO THE LEGAL GUARDIAN:

Authorization to Release Information and Assignment of Benefits: I give consent, by signing below, to Alaska Bleeding Disorder Clinics (ABDC) to release the personal date as required in the course of examinations and treatment for purposes of billing and filing insurance coverage or other financial claims related to the care provided. I consent to assign all payments for services to ABDC or persons billing on their behalf, for care preformed or services rendered by the providers where within to the patient named below. I also understand that Alaska State Law requires ABDCto report all vaccine records to the AK State Registry (VacTrack)

Assumption of Financial Responsibility: I, by signing below, assume financial responsibility for payment of fees stemming from care rendered or services provided by ABDC to the patient named below. Insurance or other coverage may pay for part of these charges, and I assume responsibility for any unpaid portion.

I understand that Pricing information and description of services may be requested. In accordance with Anchorage Municipal Code 16.130.010 (A Healthcare Transparency Policy) - ABDC will provide you with an estimate of the anticipated charges of your care, upon request. Questions welcome at any time.

If I fail to pay outstanding balances or fail to comply with an arranged payment plan, I accept all charges associated with collections from ABDC.

HIPAA Notice of Privacy Practices: I understand that ABDC provides the opportunity to view the HIPAA Privacy Practices and the rights I have regarding health information anytime requested, Questions are welcome at any time as well.

Discrimination: I understand that ABDC complies with applicable Federal civil rights laws and does not discriminate based on race, color, national origin, age, disability, or sex. Language assistance services, free of charge, are available to you. Call 907-917-9235. (TTY Not Available by Phone, but accommodations can be made)

Consent for Care:

You have the right, as a minor patient’s legal guardian, to be informed about the patient’s condition and the recommended surgical, medical,diagnostic procedure to be used so that you may make the decision whether to accept any suggested treatment or procedure after knowing the risks and hazards involved.

The consent provides us with your permission to perform or provide reasonable and necessary, medical examinations, testing, treatment and vaccines. Vaccines are offered and provided in accordance with the Centers for Disease Control (CDC) and American Academy of Pediatrics (AAP) recommended vaccination schedule as standard of care at every visit a vaccine is due.

You have the right, at any time, to decline or discontinue any or all services. You have the right to discuss the treatment plan and any orders with the provider – the purpose, potential risks, benefits, other questions, any concerns,

By signing below, you are indicating that you consent for care provided to the minor patient at this office by any Physician, Nurse Practitioner, Physician Assistant, nurse or designated individual associated with ABDC. The same care will be provided to the minor patient regardless of who accompanies the minor child, or should the child be unaccompanied. The ability to discuss patient information is kept to strict adherence to HIPAA standards and will be limited as necessary to adhere to those standards.

 

PATIENT CONSENT TO ELECTRONIC COMMUNICATIONS AND ACKNOWLEDGEMENT OF POLICY

Communication Consent: If you personally wish to communicate with ABDC via Email, Text and/or Fax, please initial the option below and provide a valid email address, text number and/or fax number.

Please initial and date the appropriate lines below.  Leave blank if you do not wish to communicate via each particular method

This consent will remain fully effective for 1 year or until it is revoked in writing. If additional testing, invasive or interventional proceduresare recommended, you will be asked to read and sign additional consent forms prior to the test(s) or procedure(s).

I certify that I have read and fully understand the above statements and hereby consent fully and voluntarily to its contents.

By signing below, you acknowledge that you have read and fully understand the ABDC Electronic Communications Policy. You have been given the risks and benefits of such services and technologies, and understand the risks associated with online communications with ABDC, and consent to the conditions as indicated herein. In addition, you agree to adhere to the policies set forth above, as well as any other instructions or guidelines that ABDC may impose for using the electronic communications.