Risk Management

Consent for Proxy Forms

Minor-aged patients are often brought to the pediatrician for non-urgent acute medical care or health supervision visits by someone other than their custodial parent or guardian. These surrogates can be members of the child’s extended family, such as a grandparent, aunt, noncustodial parent, stepparent, au pair or nanny.  There are two forms available to assist you with obtaining permission or consent from someone other than the custodial parent or legal guardian.

CONSENT FOR PROXY FOR NON-URGENT PEDIATRIC CARE is available for download (proxy click here).

PREAUTHORIZATION TO TREAT MINORS is available for download (pre-authorize click here).




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