Patient Update Form

Child 1

Insurance: PLEASE PRESENT CARD TO FRONT DESK

Mom/Guardian

Dad/Guardian

I authorize West Coast Pediatrics including its employees to

general medical psychiatric/psychological, legal, alcohol and/or drug abuse information pertaining to

1. I understand that authorizing the disclosure of this health information is voluntary and you have my consent to release medical records for all dates including all diagnostic tests for any type and reports, history, hospitalization, diagnosis, prognosis, treatment, medication and pharmacy records, correspondence, consults, statement of charges or expenses. Any and all reports of any type or character.
2. I understand that the information authorized for release may include records which may indicate the presence of a communicable or non-communicable disease.

This authorization will expire one year from the date signed. A copy or facsimile of this authorization shall be counted true and valid as original.

I give permission for the medical staff to contact me at the following numbers regarding patient care, test results, appointments, prescription and billing questions.

I hereby authorize West Coast Pediatrics to treat my child and discuss appointments and test results with these designated persons: