Authorization for Designated Agents

This form is for a Parent/Legal Guardian of children/minors (who cannot consent to their own medical care). By completing this form, a Parent/Legal Guardian can designate individuals to accompany their child or children for medical services when the Parent/Legal Guardain is unable to do so.

Today's Date

M-D-Y

Parent/Legal Guardian Name

* must provide value

How many children are you completing this form for?

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Name of Child/Minor/Patient		Date of Birth

How many adults (must be 18 or older) are you designating as an authorized agent to bring child/children into care?

Name	Relationship to Patient/Patients

I, ______, give the above person/s permission to bring my child/children to Philadelphia FIGHT Community Health Centers to receive medical treatment and to make medical decisions on behalf of my child/children as well as to receive confidential medical information about my child children. I understand and agree that:

Confidential medical information includes all information contained in my child/children's medical record and any and all information that relates to my child/children's current or future medical treatment including but not limited to insurance records regarding any such services.
Any person I designate as an authorized agent will also be designated and authorzied as an alternate emergency contact for my child/children.
Individual/s or person/s I ahve authorized as designated agent/s for my child/children must bring government issued photo identification with them, when accompanying my child/children for medical care.
This authorization will remain in effect until changed by the parent/legal guardian signed below.
This from will be scanned into my child/children's medical record.
I understand that I have the right to revoke this authorization, at any time, by sending written notification to: Philadelphia FIGHT Privacy Officer, 1233 Locust St, 5th Floor, Philadelphia, PA, 19107 OR by requesting a copy of this form from the PFCHC clinic where I receive services, completing the "Revocation" section at the bottom of this form, and returning to that PFCHC clinic.

By signing I affirm that I have reviewed, understand, and agree to the authorizations and terms listed above.

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